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ISBN: 978-0-323-04910-8

Mosbys Pharmacy Review for the NAPLEX

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Notices
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our understanding, changes in research methods, professional practices,
or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds, or experiments described herein.
In using such information or methods they should be mindful of their own safety and the safety
of others, including parties for whom they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to
check the most current information provided (i) on procedures featured or (ii) by the
manufacturer of each product to be administered, to verify the recommended dose or formula,
the method and duration of administration, and contraindications. It is the responsibility of
practitioners, relying on their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each individual patient, and to
take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors,
assume any liability for any injury and/or damage to persons or property as a matter of
products liability, negligence or otherwise, or from any use or operation of any methods,
products, instructions, or ideas contained in the material herein.
Library of Congress Cataloging-in-Publication Data
Mosbys pharmacy review for the NAPLEX. -- 1st ed.
p. ; cm.
Other title: Pharmacy review for the NAPLEX
ISBN 978-0-323-04910-8 (pbk. : alk. paper) 1. Pharmacy--Outlines, syllabi, etc. 2. Pharmacy-Examinations, questions, etc. I. Title: Pharmacy review for the NAPLEX.
[DNLM: 1. Pharmaceutical PreparationsExamination Questions. 2. Pharmacy--Examination
Questions. QV 18.2 M8935 2010]
RS98.M72 2010
6150 .1076dc22
2010003173

Vice President and Publisher: Linda Duncan


Senior Editor: Kellie White
Senior Developmental Editor: Jennifer Watrous
Publishing Services Manager: Pat Joiner-Myers
Project Manager: Melissa Lastarria
Design Direction: Jessica Williams

Printed in the United States of America.


Last digit is the print number: 9

8 7 6 5 4

3 2 1

..................................................

Contributors

....................................................................................................................................................................

LEAD CONSULTANT
MaryAnne Hochadel, PharmD, BCPS
Editor Emeritus,
ELSEVIER/Gold Standard
Clinical Assistant Professor
University of Florida
College of Pharmacy
Tampa, Florida

CONTRIBUTORS
Catherine Ulbricht, PharmD
Massachusetts General Hospital
Natural Standard Research Collaboration
Somerville, Massachusetts
Erica Rusie, PharmD
Natural Standard Research Collaboration
Somerville, Massachusetts

iii

..................................................

Reviewers

...................................................................................................................................................................

Laurel E. Ashworth, PharmD


Professor of Pharmacy Practice
Mercer University College of Pharmacy and
Health Sciences
Atlanta, Georgia
Paul Juang, PharmD, BCPS
Assistant Professor
Department of Pharmacy Practice
St. Louis College of Pharmacy
St. Louis, Missouri
Julie P. Karpinski, PharmD, BCPS
Director, Drug Information
Assistant Professor, Pharmacy Practice
Concordia, University School of Pharmacy
Mequon, Wisconsin
Trisha LaPointe, PharmD, BCPS
Assistant Professor of Pharmacy Practice
Massachusetts College of Pharmacy and Health
Sciences
Department of Pharmacy Practice
School of Pharmacy-Boston
Boston, Massachusetts
Donna Larson, EdD, MT(ASCP)DLM
Dean of Allied Health
Mt. Hood Community College
Gresham, Oregon
Terri L. Levien, PharmD
Clinical Associate Professor
Pharmacotherapy Department
College of Pharmacy
Washington State University Spokane
Spokane, Washington

iv

David Nissen, PharmD


Pharmacy Informatics
Missouri Baptist Medical Center
St. Louis, Missouri
Lindsay B. Palkovic, PharmD, BCPS
Assistant Professor of Clinical Pharmacy
Philadelphia College of Pharmacy
University of the Sciences in Philadelphia
Philadelphia, Pennsylvania
Puja Patel, PharmD
Drug Information Resident 2009-2010
Mercer University and Solvay Pharmaceuticals
Atlanta, Georgia
Karen J. Tietze, BS, PharmD
Professor of Clinical Pharmacy
Department of Pharmacy Practice and Pharmacy
Administration
Philadelphia College of Pharmacy
University of the Sciences in Philadelphia
Philadelphia, Pennsylvania
Bradley M. Wright, PharmD, BCPS
Assistant Clinical Professor of Pharmacy Practice
Harrison School of Pharmacy
Auburn University
Mobile, Alabama

..................................................

Introduction

....................................................................................................................................................................

Mosbys Pharmacy Review for the NAPLEX reflects the


unique attributes and dynamic role of the pharmacist
in healthcare. The main objective of the text is to
provide a useful, current, and comprehensive review
of relevant pharmacy topics to the candidate in

preparation for the NAPLEX examination.

Although this text is for use primarily by NAPLEX


candidates, the concise format of the materials would
make an excellent review for pharmacy students,
pharmacy instructors, or for practicing pharmacists.
Users of this guide will benefit from the review of a variety
of topics relating to the science and art of pharmacy
practice, including general reviews of medication
treatments for commonly encountered disease states and
therapeutic areas. Candidates will benefit from keeping
this book handy as they enter practice to provide a quick
go-to reference regarding pharmaceutical calculation
methods, patient counseling, and more.

Key features of this review include:

Electronic flashcards and two mock timed examinations


on the enclosed CD-ROM allow the student to test
comprehension and to demonstrate competency under

testing conditions. The NAPLEX s focus on three areas


of pharmaceutical practice is accurately reflected in the
CD-ROM content.

How to Use This Book


It is best for a candidate to approach preparation for

the NAPLEX in a logical and orderly manner, with time


given to consistent review of all areas of importance to
the examination. The format of this text will help the
student with his or her review and organization of study.
The subject matter, including patient-based cases, will

address all areas of the NAPLEX competency statements,


in roughly the same proportion that they are represented

on the NAPLEX examination. The three main areas of


study are:

Over 1,600 NAPLEX -oriented study questions.

Area One: Assure Safe and Effective Pharmacotherapy


and Optimize Therapeutic Outcomes

An easy to follow outline format for each chapter to


organize and quickly overview each area of importance.

Area Two: Assure Safe and Accurate Preparation and


Dispensing of Medications

Pharmacist-oriented questions at the conclusion of each


chapter include thorough rationales at the end of the book
to aid in comprehensive review and study. The rationales
help ensure comprehension and understanding of the
material, rather than focus on direct memorization or
rote review.

Area Three: Provide Health Care Information and


Promote Public Health

Patient-based review questions within the therapeutic


review chapters are presented with an emphasis on
appropriate patient counseling by the pharmacist.

After a thorough review of the text contents, the


student can use the CD-ROM to test medication familiarity
and competency under simulated test circumstances. A
well-prepared student who has studied to learn and
understand the material will be able to display his or her
knowledge and will enhance his or her potential for
licensure.

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..................................................

Contents

....................................................................................................................................................................

Preparing for the NAPLEX

. . . . . . . . . . . . 1

SECTION I: PHARMACEUTICAL
PRACTICE

23

Womens Health Issues . . . . . . . . . . . . . . 247

24

Immunology and Vaccines . . . . . . . . . . . . 258

25

Immunosuppressants . . . . . . . . . . . . . . . 266

Pharmaceutical Calculations . . . . . . . . . . . . 3

Compounding . . . . . . . . . . . . . . . . . . . 18

Drug Information Resources . . . . . . . . . . . 27

SECTION III: CONSUMER-DIRECTED


HEALTHCARE

Dispensing . . . . . . . . . . . . . . . . . . . . . 37

26

Nonprescription Products . . . . . . . . . . . . 271

Patient Education . . . . . . . . . . . . . . . . . 56

27

Nutrition . . . . . . . . . . . . . . . . . . . . . . 284

Herbs and Dietary Supplements . . . . . . . . . 67

Laboratory Tests . . . . . . . . . . . . . . . . . 79

SECTION II: PHARMACOTHERAPY


IN PRACTICE

SECTION IV: MISCELLANEOUS


TOPICS IN PHARMACY PRACTICE
AND SCIENCE
28

Basic Pharmacokinetics . . . . . . . . . . . . . 289

29

Pharmacogenomics . . . . . . . . . . . . . . . . 294

30

Toxicology . . . . . . . . . . . . . . . . . . . . . 299

Antiinfective Agents . . . . . . . . . . . . . . . . 87

10

Cardiovascular Disorders . . . . . . . . . . . . 103

11

Dermatologic Disorders . . . . . . . . . . . . . 132

12

Common Endocrinologic Disorders . . . . . . . 138

Appendix A

13

Gastrointestinal Disorders . . . . . . . . . . . . 150

Drug Interactions . . . . . . . . . . . . . . . . . . . . 305

14

Geriatrics . . . . . . . . . . . . . . . . . . . . . . 161

15

Human Immunodeficiency Virus/Acquired


Immunodeficiency Syndrome (HIV/AIDS) . . . 175

16

Kidney Disorders . . . . . . . . . . . . . . . . . 180

17

Oncology . . . . . . . . . . . . . . . . . . . . . . 186

18

Pain Management . . . . . . . . . . . . . . . . . 197

19

Psychiatric Disorders . . . . . . . . . . . . . . . 209

20

Respiratory Disorders . . . . . . . . . . . . . . 223

21

Arthritis . . . . . . . . . . . . . . . . . . . . . . . 231

22

Seizure Disorders . . . . . . . . . . . . . . . . . 237

Appendix B
Federal Pharmacy Law . . . . . . . . . . . . . . . . . 308

Appendix C
Foreign Pharmacy Graduate Equivalency
Examination . . . . . . . . . . . . . . . . . . . . . . . 311

Answers and Rationales . . . . . . . . . . . . 313


Index . . . . . . . . . . . . . . . . . . . . . . . 385

vii

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..................................................

Preparing for the NAPLEX

1
CHAPTER

....................................................................................................................................................................

GENERAL INFORMATION
NAPLEX
The North American Pharmacy Licensure Exam (NAPLEX)
is the clinical aptitude test developed by the National
Association of Boards of Pharmacy (NABP) and
administered to pharmacy graduates to assess the
competency of candidates for pharmacy practice. It is a
requirement to obtain pharmacy licensure in all 50 states.
MPJE
The Multistate Pharmacy Jurisprudence Examination
(MPJE) is the examination developed by the NABP to test
the candidates competency and knowledge of federal
and state pharmacy law. The questions are customized to
the specific law in each state. It is required for a pharmacy
license by 44 states and the District of Columbia.

REGISTRATION
Candidates wishing to register for the NAPLEX with or
without the MPJE must contact the board of pharmacy in
the state they are seeking licensure or their school of
pharmacy and complete a paper examination registration
form for each examination. Candidates may also
choose to register online for the NAPLEX or MPJE at
www.napb.net. Candidates should check the website to
see if their state participates in online registration.
Candidates may submit their registration, paper or
online, before graduation; however, the state board of
pharmacy will authorize eligibility only after all
graduation requirements have been met.
The NAPLEX and MPJE may be taken on the same day,
if time permits; however, it may be beneficial to take the
examinations on separate days due to the diversity of the
material.

FEES
Examination fees:
 NAPLEX: $465 per examination
 MPJE: $185 per examination
For those who wish to change their appointments, an
additional fee of $50 will be charged. Candidates who
withdraw from taking the NAPLEX will receive a partial
refund of $140; those who withdraw from taking the MPJE
will receive a partial refund of $65. Cancellations or

rescheduling the exam must be done at least two business


days before the scheduled appointment.
Fees are payable to the National Association of
Boards of Pharmacy or NABP and submitted in the form
of a money order, bank draft, or certified check.
Personal check or cash is not accepted.
After registration, candidates will receive an
authorization to test (ATT) letter, which confirms the
candidates eligibility by the state board of pharmacy.
Upon receipt, candidates can schedule their
appointments for examination and have one year to do so.
The ATT and application expires after one year.
The NABP website, www.nabp.net, can provide the
most current information.

ANSWER FORMAT OF THE NAPLEX


The computer-adaptive NAPLEX examination consists of
185 multiple-choice questions; however, only 150
questions are scored. The remaining 35 are considered
pretest questions, which have no impact on the final
score. These questions are used to help develop future
tests. Because no indication is given to determine the
scored questions versus the nonscored questions, it is to
test-takers advantage to answer all questions to the best
of their knowledge.
The test also uses case/scenario-based format (i.e.,
patient profiles) and K-type multiple choice questions in
which three choices are given and candidates select from
five combinations of those three choices:
I. Choice 1
II. Choice 2
III. Choice 3
A. I only
B. III only
C. I and II
D. II, III
E. I, II, III

TEST STRUCTURE OF THE NAPLEX


The NAPLEX has three core areas:
1. Ensure safe and effective pharmacotherapy and
optimize therapeutic outcomes (approximately 54% of
the exam).
2. Ensure safe and accurate preparation and dispensing
of medications (approximately 35% of the exam).

CHAPTER 1

PREPARING FOR THE NAPLEX

3. Provide health care information and promote public


health (approximately 11% of the exam).
Candidates may refer to the NAPLEX blueprint for more
detailed dissection of the topics covered on the
examination at www.nabp.net.
If the candidate does not pass the exam, he/she may
retake the exam after 91 days for the NAPLEX and after
30 days for the MPJE.

ADMINISTRATION PROCESS
NAPLEX
The NAPLEX has 185 questions to be taken in a 4 hour
and 15 minute time period. There is an optional
10 minute break after approximately two hours of
testing time.
The test is presented in a computer-adaptive testing
format, which means that each answered question will
determine the difficulty of the next. A correctly answered
question in a series will be followed by a harder question.
An incorrect response will be followed by an easier
question.
Every question must be answered in the order it is
presented. The test-taker cannot return to previous
questions and change answers, so all responses are final.
Due to the adaptive nature of the exam, questions also
cannot be skipped because each response determines the
next question.
MPJE
The test consists of 90 questions; only 60 are scored. The
exam is to be taken in two hours with no break.

TEST TAKING STRATEGY


 Arrive to the testing center at least 30 minutes before

the examination to allow time to check-in.


 Take a snack for the 10-minute break during the

NAPLEX.
 Take proper identification (refer to candidate

bulletin).
 Relax the night before the exam and eat a nutritious

breakfast the morning of the examination.


 Although there is no penalty for guessing, you still

want to make your best effort to choose a correct


response.
 Make educated guesses. If you can rule out one or more
answer choices, you have a better chance of selecting
the right answer.
 Limit your time on any one question; as a general
rule of thumb, be halfway through the NAPLEX by the
10 minute break.
 Use various study guide materials, including text
books, flashcards, class notes, and practice tests.
Take a full-length practice test before the
examination.

 Do not try to cram new material. Create a study

schedule that allots adequate time for the various


sections of the NAPLEX.

SCORE RESULTS
NAPLEX
The scaled NAPLEX scores range from 0 to 150 with a
minimally acceptable level of performance on the
examination reflected by a score of 75. To obtain a score,
the candidate has to complete at least 162 questions.
Test scores are not given directly to the candidate;
instead, they are forwarded by the NABP to the board of
pharmacy from which the candidate is seeking licensure.
Depending on the state, candidates may transfer
their scores to more than one state. Candidates should
check the website (www.nabp.net) about the score
transfer program. The state to which they wish to
transfer their scores should also be contacted for more
information.
MPJE
The minimum acceptable passing score on the MPJE
scale is 75. To obtain a score, the candidate has to
complete at least 77 questions. MPJE scores cannot be
transferred between states. Candidates must take the law
portion for each individual state in which they are seeking
licensure.

THE PRE-NAPLEX
The NABP also offers the pre-NAPLEX. It is designed to
familiarize the test-taker with the testing experience.
The pre-NAPLEX is the only practice exam written and
developed by the NABP.
There are 50 questions on the pre-NAPLEX and two
forms are available. The cost for each practice
examination is $50. The candidate must register with the
website and set up a username and password. Each
candidate may take the pre-NAPLEX two times but must
complete the first test before starting another one and
pay for each test. The test may be taken with any
computer with Internet access, including at home, a
school, a library, and at any time. The scores are scaled
and interpreted similar to the NAPLEX.

NAPLEX AND MPJE REGISTRATION BULLETIN


A free bulletin regarding the NAPLEX and MPJE is offered
to all candidates. Topics covered include registration
procedures, testing appointment information, NAPLEX
and MPJE administration, NAPLEX and MPJE score
results, the pre-NAPLEX, and NAPLEX score transfer
information. It is available online at http://www.nabp.net/
ftpfiles/bulletins/NAPLEXMPJE.pdf or through your state
board of pharmacy.

SECTION

PHARMACEUTICAL PRACTICE

..................................................

Pharmaceutical Calculations

2
CHAPTER

....................................................................................................................................................................

SYSTEMS OF MEASURE
Summary of conversion between metric, apothecaries
and avoirdupois systems:
Note that in the apothecaries and avoirdupois systems
there is only one common unit of measure, the grain. The
other measurement units carry different values when
comparing the systems. When converting between the two,
the pharmacist should convert the value down to the grain
amount in the one system, then convert to the other system.
Per the United States Pharmacopeia, 1 grain 64.8 mg.
METRIC SYSTEM
Mass
gram (g)
Length meter (m)
Volume liter (L)
1 cubic centimeter (cc) equals approximately 1
milliliter (mL) and weighs 1 g

Prefixes
kilohectodekadecicentimillimicronanopico-

103
102
10
101
102
103
106
109
1012

1 thousand (1000) times the basic unit


1 hundred (100) times the basic unit
1 ten (10) times the basic unit
1 tenth (0.1) times the basic unit
1 hundredth (0.01) times the basic unit
1 thousandth (0.001) times the basic unit
1 millionth times the basic unit
1 billionth times the basic unit
1 trillionth times the basic unit

APOTHECARIES SYSTEM

Volume (fluid)

60 minims
8 drams
16 fluid ounces
2 pints
8 pints (4 quarts)

1
1
1
1
1

fluid drachm (or dram)


fluidounce
pint
quart
gallon

Mass (weight)
12 ounces
8 drams (480 grains)
1 drams

1 pound
1 ounce (apothecaries)
27.34375 grains

1 dram
3 scruples
20 grains

1.772 grams
1 dram
1 scruple

AVOIRDUPOIS SYSTEM
A system of masses based on a pound weighing 16 ounces
mostly commonly used in the United States for
commercial purposes.

Volume
1 fluid ounce

8 fluidram

Mass
437:5 grains
1 ounce
28:349523 grams 1 ounce
16 drams
1 ounce avoirdupois
16 ounces
1 pound lb:
UNITS OF AMOUNT OF SUBSTANCE
1 Mole Molecular Weight in grams or Relative Molecular
Mass in grams
1 Molar solution Gram Molecular Weight or Relative
Molecular Mass in grams in 1 Liter
1 mol 1000 millimols (normally written as 1000 mmol)
1 millimole 1000 micromoles
1 micromole 1000 nanomoles
1 mol / liter 1 mmol / mL, 1 mmol / liter 1 micromole / mL
Millimole (mmol): A millimole (mmol) is a molecular
weight expressed in milligrams.
The number of millimoles of a substance is calculated
by dividing the number of milligrams of a substance by
the molecular weight (MW) of the substance:
mmols mg/MW

RATIO AND PROPORTIONS


RATIO
A ratio is a comparison of two numbers. In pharmacy
calculations, a ratio can be used to express strength of
drug concentration.
Example: A 1:25 solution of wintergreen oil means that
1 mL of wintergreen oil is contained in each 25 mL of solution.
3

SECTION I

PHARMACEUTICAL PRACTICE

PROPORTIONS
A proportion represents the equality between two ratios.
A proportion is an equation with a ratio on each side. It is
a statement that two ratios are equal. This mathematical
concept is often used in community pharmacy.

Example:
If 5 tablets contain 1625 mg of acetaminophen, how many
tablets should contain 2925 mg?

Solution:

5 tablets 1625 milligrams


X tablets 2925 milligrams
X 9 tablets; answer
5 tablets X tablets

1625 mg
2925 mg

X 9 tablets

Relevant measurements and conversions


1 in
2.54 cm
1m
39.37 in
1 kg 2.2 lb
1g
15.4324 gr (round to 15.4 gr)
1 fl oz. 29.5729 mL (round to 29.6 or 30 mL)

DIMENSIONAL ANALYSIS
Dimensional analysis is a method of manipulating units to
solve mathematical equations. The process allows you to
cancel out unwanted units leaving only those units you
want your answer to be expressed as.

Example:
A pharmacist wants to know how many inhalers should
be dispensed to a patient to provide a 60-day
supply of fluticasone. The recommended daily dose
is 250 mcg twice daily. The commercial inhaler delivers
220 mcg per metered dose and contains 60 metered
inhalations.

Solution:

220 mcg  2 (twice daily) 440 mcg/day

440 mcg
day

1 inhalation
220 mcg

1 inhaler

 60 days 2 inhalers
60 inhalations

The pharmacist should dispense 2 inhalers for a 60-day


supply.

INTERPRETATION OF MEDICATION ORDERS


Example 1:
A prescription for prednisone 5 mg should be taken as
follows:
2 tablets three times daily the first day; 1 tablet three
times daily on the second day; 1 tablet twice daily for
7 days; and 1 tablet daily thereafter.
How many tablets should be dispensed for a 30-day supply?

Solution: Dispense 44 tablets in total

Example 2:
A prescription is to be taken as follows: 1 tablespoon ac
and hs for 7 days. What is the minimum volume that
should be dispensed?

Solution:

achs before meals and at bedtime


1 tablespoon 15 mL
Patient needs to receive four doses per day for 7 days.
15 mL  4 doses  7 days 420 mL

DOSAGE BASED ON DROPS


Certain medications that are administered or dispensed to
a patient come in the form of liquids and are administered
as drops. This section provides practice for calculations
for these types of prescriptions.
If a pharmacist counted 30 drops of a drug in filling a
graduated cylinder to the 1.5 mL mark, how many drops
per milliliter did the dropper deliver?

Solution:
30 drops gtt 1:5 mL

X gtts
1 mL
X 20 drops per mL; answer

PERCENTAGE AND RATIO STRENGTH CALCULATIONS


EXPRESSED AS V/V, W/W, AND W/V
Certain prescriptions are expressed in weight/weight
(w/w), volume/volume (v/v), and weight/volume (w/v)
percentages. To properly process prescription orders of
this nature, the pharmacist must be able to make
conversions and calculations with these units.
Concentration quantity of solute divided by the
quantity of preparation.
V/V: If the solute and the preparation are expressed in
the same units, then concentration is dimensionless.
For example, 10 mL of alcohol dissolved in a sufficient
quantity of water to make 40 mL of solution is
dimensionless: 10 mL/40 mL 0.250 (or 25% v/v).
W/W: If the quantity of solute and of the preparation are
expressed in the same units of weight, the concentration
is dimensionless. If 10 g of charcoal are mixed with 65 g
of another powder to make a total of 75 g, the charcoal
concentration is 10 g/75 g 0.133 by weight (or 13.3% w/w).
W/V: When a solute is measured by weight and the
solution by volume, concentration is not dimensionless.
If 1.25 g of NaCl is dissolved in sufficient water to make
55 mL of solution, the concentration is 1.25 g/55 mL
0.0227 g/mL (w/v). The % w/v is expressed as #g/100 mL
(e.g., 2.27% or 2.27 g/100 mL).

Example 1:
How many grams of drug should be used to prepare 120
grams of a 2% w/w solution in water?

Solution:
2 grams drug
100 grams drug
2:4 grams, answer

120 grams mixture 

CHAPTER 2

Example 2:
What is the percentage strength (w/v) of a solution of
drug if 40 mL contain 5 grams?

The coal tar (active ingredient) is added to a diluent


(petroleum) currently containing no coal tar.
25% 240 grams

15%
X grams
X 143.7 grams
144 grams of coal tar, answer

40 mL
100 %

5 grams
X %

PPM AND PPB (PARTS PER MILLION AND PARTS


PER BILLION)
When ppm or ppb is used as a designation for
concentration, some systems are w/w, some are v/v and
some are w/v. Concentration is always a ratio or fraction
in w/w and v/v situations. Weight by volume (w/v)
concentrations are always defined in terms of grams and
milliliters. The same default rules are followed as for
percentage systems.

Example:
Express 2 ppm of ferrous gluconate in water in percentage
strength and ratio strength.

Solution:

2 ppm 2 parts in 1,000,000 parts


1:500,000  ratio strength
0.0002%  percentage strength

DILUTION, CONCENTRATION, AND ALLIGATION


DILUTION OF AN INGREDIENT
Dilution is the addition of diluent to the ingredient or an
admixture of the ingredient with solutions to achieve a
lower concentration of solution.

Example:
A 1:5000 dilution of drug A is requested. If 1 mL of drug A
injection 1:200 is mixed with sterile water for injection,
how many mL of water will be needed?

ALIQUOT METHOD (ALLIGATION)


Alligation is a method that is particularly useful when
mixing two or more preparations of known strengths to
prepare a mixture of an intermediate desired strength.
The final mixture will be an average of the individual
strengths, which are calculated as proportional parts.
Alligation Alternate and Alligation Medial are methods
that can be used to solve any type of dilution or
concentration problem, including concentrations
expressed in mg/mL, ratios, mixtures of liquids of known
specific gravities, etc. The strengths of all preparations
being mixed and the final mixture are expressed in a
common denomination (of weight, volume, percentage,
etc.) when setting up the alligation equation. When
diluting a preparation, the strength of the diluent is
considered to be 0%. When increasing the strength of a
given mixture by adding more drug/active ingredient, the
strength of the active ingredient to be added is
considered to be 100%. A final proportion allows a
correlation between the parts and any specific
denomination needed.

Example 1:
A pharmacist has a 60% solution and a 15% solution.
She needs a 40% solution to compound a medication.
What is the proportion of the 60% and 15% solutions that
would make a 40% solution? This example will use the
process of Alligation Alternate to calculate the quantities
of each mixture needed to make the final mixture of the
desired strength:

Solution:
60%

1
1
1 mL
X
200
5000
0.005 0.0002(X)
25 mL X
25 mL  1 mL 24 mL, answer
CONCENTRATION OF AN INGREDIENT
Concentration is the addition of an active ingredient or
evaporation of the diluent from an active ingredient to
create a more concentrated solution.

Example:
How many grams of coal tar containing 25% (w/w) should
be added to petrolatum to prepare 240 grams of coal tar
containing 15% (w/w)?

25

60  40 20
15  40 25

40%
15%

Solution:

Solution:

Solution:

X 12:5%; answer

Pharmaceutical Calculations

20 parts

25 20 45

25 parts of the 60% solution combined with 25 parts of


15% solution would yield 45 parts of a 40% solution.

ISOTONIC SOLUTIONS
Osmosis occurs when a solvent (e.g.,water) passes
through a semipermiable membrane from a lowconcentration solution into a high-concentration one, with
the result that the concentrations become equalized.
The pressure that causes this occurrence is known as
osmotic pressure.
A solution that exerts the same osmotic pressure
as a specific body fluid is known as isotonic. If the
solution exerts an osmotic pressure lower than that of
specific body fluid, the solution is hypotonic. If the actual
solution exerts an osmotic pressure higher than that of
specific body fluid, the solution is considered hypertonic.

SECTION I

PHARMACEUTICAL PRACTICE

Example:

Example:

How much sodium chloride is needed to adjust the


following prescription to isotonicity? (E value [sodium
chloride equivalents] for zinc sulfate is 0.15)
Zinc sulfate 2%
NaCl
q.s.
Purified water q.s. 60 mL
Make isotonic solution

How much calcium chloride (CaCl22H2O) is required to


prepare 100, 1 mL ampules containing 10 mEq per mL?
(mw 147)

Solution:

100 mL  10 mEq=mL 1000 mEq


1 mEq

Solution:

1 mEq
1000 mEq

73; 500 mg
73:5 mg
X

If sodium chloride is only being used to provide the 60 mL


isotonic solution: 60 mL  0.9% 0.54 g (or 540 mg)
Step 1: 60 mL  2% 1.2 g (or 1200 mg) of zinc sulfate
required to fill the prescription
Step 2: 1200 mg is equivalent to 1200  0.15 180 mg
of sodium chloride
Step 3: 540 mg  180 mg 360 mg (or 0.36 g), answer

ELECTROLYTE SOLUTIONS
Electrolyte solutions are used to treat fluid and electrolyte
disturbances. They may be prepared as oral solutions,
syrups, dry granules intended to be dissolved in water or
juice to make an oral solution, or oral tablets or capsules, and
they are also commonly prepared as intravenous infusions.
To convert electrolytes in solution (expressed as
milliequivalents [mEq] per unit volume to weight per unit
volume or vice versa), the following calculation may be used:
mg  Valence
mEq
Atomic; molecular; or formula weight
mg

mEq  Atomic; molecular; or formula weight


Valence

Table 2-1

Valences and Atomic Weights of Select Ions

Ion

Formula

Aluminum
Ammonium
Acetate
Bicarbonate
Calcium
Carbonate
Chloride
Citrate
Ferrous
Ferric
Gluconate
Lactate
Lithium
Magnesium
Phosphate
(mono)
Phosphate (di)
Potassium
Sodium
Sulfate

Al3
NH4
C2H3O2
HCO3
Ca2
CO32
Cl

C6H5O73
2
Fe
Fe3
C6H5O3
C3H5O3
Li
Mg2
H2PO4
HPO42
K
Na
SO42

Atomic/Formula
Weight

Valence

27
18
59
61
40
60
35.5
189
56
56
195
89
7
24
97

3
1
1
1
2
2
1
3
2
3
1
1
1
2
1

96
39
23
96

2
1
1
2

From Zatz J: Pharmaceutical Calculations, ed 4, Hoboken, NJ,


2005, John Wiley & Sons, Inc., p. 267.

147 mg
73:5 mg
2

X 73:5 g, answer

TPN CALCULATIONS
Total parenteral nutrition (TPN) provides all of the
patients daily nutritional requirements and generally
contains dextrose (carbohydrate), amino acids (protein
source), vitamins, trace minerals, electrolytes, and fat
emulsions. TPN solutions may also include insulin and
occasionally therapeutic drugs. The amount of protein,
dextrose, and fat are calculated based on the patients
daily kcal (calories) needed and available stock solutions.
Other ingredients do not contain calories.

Example:
A patient needs 1600 kcal/day. The physician has
ordered that the patient receive 65% of the daily calories
(kcal) from carbohydrates, 10% from protein, and 25%
from fat.
Calculate the amount (volume) needed to supply the
dextrose, protein, and fat calories from these pharmacy
stock solutions:
Dextrose 65%, amino acid 10%, fat 25%
First, determine how many kcal the patient needs from
each component:
1600 kcal  65% 1040 kcal from dextrose
1600 kcal  10% 160 kcal from protein
1600 kcal  25% 400 kcal from fat
Next, convert these kcals into grams:
1040 kcal  1 gram=3:4 kcal 305:9 grams dextrose
160 kcal  1 gram=4 kcal 40 grams protein
400 kcal  1 gram=9 kcal 44 grams fat
Then, calculate how many milliliters are needed from
each stock solution:
305.9 grams  100 mL/ 65 grams 470.6 mL from
dextrose 65%
40 grams  100 mL/ 10 grams
400 mL from amino
acid 10%
44.4 grams  100 mL/ 25 grams 177.6 mL from fat 25%
NOTE:
Carbohydrate contains 3.4 kcal/g
Amino acid contains 4 kcal/g
Fat contains 9 kcal/g

CALCULATION OF DOSES
There are a variety of ways to determine doses of drugs
including by age, body weight, surface area, creatinine
clearance, and other pharmacokinetic parameters.

CHAPTER 2

CREATININE CLEARANCE
When using the below equations, two factors to consider
are (1) the serum creatinine is at steady state and (2) the
weight, gender, and age of the individual reflect normal
muscle mass.
Cockcroft-Gault equation
To estimate renal function for the purpose of drug
dosing, creatinine clearance should be measured or
estimated.

For males:
CrCl

140  Patient0 s age in years  Body weight in kg


72  Serum creatinine in mg=dL

For females:
CrCl 0:85  CrCl determined using formula for males
If the individual is obese or not within 30% of their ideal
body weight, other methods of calculating creatinine
clearance should be used. Ideal body weight (IBW) or
adjusted body weight (ideal body weight plus 40% of
obese weight) instead of actual body weight in the
Cockcroft-Gault equation will provide a better estimate
of creatinine clearance.

The average BSA of an adult is 1.73 m2.

CALCULATIONS FOR PEDIATRIC DOSES


Various pediatric formulas have been used historically to
calculate APPROXIMATE pediatric dosages.
Youngs rule, based on age:
Age
 Adult dose Dose for child
Age 12
Frieds rule for infants:
Age in months
 Adult dose Approx: dose for infant
150

Clarks rule, based on weight:


Weight in lb  Adult dose
Dose for child
150
BSA approximation of childs dose:
Child BSA
 Adult dose Approx: dose for child
1:73 m2

STOCK SOLUTIONS
A stock solution, commonly referred to as bulk bottle, is a
large volume of a reagent (in chemistry) or in this case,
medication. These stock solutions can be prepared by a
manufacturer or compounded in the pharmacy.
Pharmacists typically take stock solutions and use them
to prepare weaker solutions of medications or chemicals
for laboratory or clinical use.

Example:
How many mL of a 0.5% gentian violet stock solution is
needed to prepare 1 pint of a 1:2000 solution?

Solution:
Step 1: Determine the quantity of the final solution:
1 pint 946 mL,
so

1g
X grams

200 mL
946 mL
X 0:473 grams

Step 2: Determine the amount of available solution needed


to obtain the determined quantity (0.5% gentian violet
solution contains 0.5 grams in 100 mL of solution):
0:5 g
0:473 grams

100 mL
X mL
X 94:6 mL; estimate 95 mL

IBW for males in kg 50 (2.3)(Height in inches > 60)


IBW for females in kg 45 (2.3)(Height in inches > 60)

BODY SURFACE AREA


The practioner may need to take into account body
surface area as a possible variable when determining drug
dosage (e.g., chemotherapy).
Body Surface Area (BSA) The Mosteller Formula:
r
Height cm  Weight kg
2
BSAm
3600

Pharmaceutical Calculations

RECONSTITUTION OF DRY POWDERS


Many drugs (antibiotics, steroids, and biologics) that are not
stable in solution are prepared as dry-filled solids or
lyophilized powders. Prior to use, these dry powders must
be reconstituted as a solution with a suitable diluent in the
proper volume to give specified concentration (usually
provided in the package insert). Occasionally, the physician
may prescribe a final concentration different from the one
provided by the manufacturer. Also, in some cases, the
pharmacist needs to determine if the powdered drug
contributes to the final volume of the reconstituted solution
before modifying the label instructions.

Example:
The package information of a vial containing 30 million
units of penicillin G potassium specifies that when the
appropriate amount of sterile solvent is added to dry
powder, the resulting concentration is 500,000 units per
mL. How many milliliters of sterile water for injection
are needed to prepare the following solution?
(Note: the powder accounts for 8 mL of the final volume)
Penicillin G potassium 30,000,000 units
Sterile water for injection
Provide a solution containing 500,000 units per mL
500; 000 units
1 mL

30; 000; 000 units X mL


X 60 mL
60 mL  8 mL 52 mL, answer

SECTION I

PHARMACEUTICAL PRACTICE

INTRAVENOUS INFUSIONS, PARENTERAL


ADMIXTURES, AND FLOW RATES
Intravenous infusions are large volumes of sterile,
aqueous preparations administered intravenously
(through a vein) over an extended period of time.

Example:
An order is written for 25,000 units of heparin in 250 mL of
D5W to infuse at 2000 units/hr. What is the correct rate of
the infusion (in mL/hr)?

Solution:
Concentration of IV
IV rate
Concentration of IV

Total amount of drug


Total volume
Dose desired
Concentration of IV
25;000 units of heparin
250 mL of D5W

Concentration of IV 100 units=mL of heparin


2000 units=hr
IV rate
100 units=mL
IV rate 20 mL=hr

References
Ansel H, Stoklosa M: Pharmaceutical Calculations, ed 12,
Baltimore, MD, 2005, Lippincott Williams & Wilkins.
Bhatt SHL: Aminoglycoside Pharmacokinetics and
Therapeutics, MCPHS Boston Campus, MA, 2006, White
Hall.
Institute of the Certification of Pharmacy Technicians
(ICPT): ExCPT Exam for the Certification of Pharmacy
Technicians. Available at http://www.nationaltechexam.
org/pdf/math_questions-answers070618.pdf, Accessed
December 24, 2008.
London, Eastern and South East Specialist Pharmacy
Services. Available at http://www.londonpharmacy.nhs.
uk/educationandtraining/prereg/supportMaterial/
calculations/download/Calculations%20WorkBook%
202005.pdf, Accessed December 24, 2008.
Pearson J, Powers M: Systematically Initiating Insulin. The
Staged Diabetes Management Approach, Diabetes Educ
32(Suppl 1):23s, 2006.
Shargel L: Applied Biopharmaceutics & Pharmacokinetics,
New York, 2005, McGraw-Hill Medical Publishing
Division, pp 4346.
Zatz J: Pharmaceutical Calculations, ed 4, Hoboken, NJ,
2005, John Wiley & Sons, Inc, pp 3033.
Mosteller RD: Simplified Calculation of Body Surface Area,
N Engl J Med 317:1098, (letter) 1987.

Parenteral admixtures are a sterile preparation that involves


the combination of one or more drugs to large-volume.

REVIEW QUESTIONS

Example:

(Answers and Rationales on page 313.)

A patient weighs 170 pounds. A pharmacist receives a


prescription order for 0.25 mg amphotericin B per
kilogram body weight. How many milliliters of a 25 mg/
10 mL solution are needed to supply the dose, which will
then be diluted in 500 mL of 5% dextrose?

Solution:
170 lb
77 kg patient
2:2 lb
0:25 mg  77 kg 19:25 mg dose needed
25 mg
10 mL

19:25 mg
X mL
X 7:7 mL, answer
Calculating IV flow or drip rates are necessary to ensure
that the patient is receiving the desired amount of drug
that was ordered.

Example:
If 20 mg of drug is added to a 750 mL parenteral fluid, what
flow rate, in millilters per hour, will deliver 2 mg of drug
per hour?

Solution:
20 mg 750 mL

2 mg
X mL
X 75 mL per hour, answer

1. A patient is prescribed 10 mEq of potassium daily.


The source of potassium chloride in the pharmacy
is 5 mEq/mL in 1 mL vials. How many vials per day is
needed for the patient?
a. 0.5 vial
b. 1 vial
c. 2 vials
d. 1.5 vials
2. How much elemental iron is present in every
150 mg of ferrous sulfate (FeSO4  7H2O)?
(Atomic weights are iron 55.9; sulfur 32.1;
oxygen 16.0; and hydrogen 1.0. Iron has
valences of 2 and 3)
a. 25 mg
b. 30 mg
c. 48 mg
d. 54 mg
e. 60 mg
3. A 130-lb patient has a creatinine clearance rate
of 40 mL/min. Assuming Drug X is eliminated
exclusively by renal mechanisms, what maintenance
dose should be administered if the normal
maintenance dose is 3 mg/lb of body weight?
a. 50 mg
b. 100 mg
c. 150 mg
d. 200 mg
e. 250 mg

CHAPTER 2

4. An IV medication is available as 3.5 g/ 500 mL with


a strength calculation of 0.25 mg/kg/min is
prescribed to a 130-lb patient. What is the infusion
rate in mL/hour?
a. 2.1 mL/ hr
b. 126.6 mL/ hr
c. 278.6 mL/ hr
d. 6,203.4 mL/ hr
5. Which of the following is an invalid DEA number?
a. BT5555555
b. DB1294658
c. AR7532648
d. MA2643713
e. All of the above are valid
6. How many quarts are in two gallons?
a. 2 quarts
b. 4 quarts
c. 8 quarts
d. 16 quarts
7. How many fluid ounces are in a quart?
a. 4 fluid ounces
b. 8 fluid ounces
c. 16 fluid ounces
d. 32 fluid ounces
8. How many teaspoons are in one pint?
a. 31.5
b. 47.3
c. 94.6
d. 104.2
9. A patient is prescribed 20 mEq of potassium
chloride daily. The source of potassium chloride
in the pharmacy is 2 mEq/ mL in 20 mL vials.
How many mL per day are needed for this patient?
a. 1 mL
b. 2 mL
c. 10 mL
d. 20 mL
10. A patient is prescribed 10 mEq of potassium
chloride daily. The source of potassium chloride in
the pharmacy is 2 mEq/ mL in 20 mL vials. How
many mL per day are needed for this patient?
a. 0.5 mL
b. 1 mL
c. 5 mL
d. 10 mL
11. How much sodium chloride is needed to make an
isotonic 100 mL solution?
a. 0.45 g
b. 0.90 g
c. 1.32 g
d. 1.53 g
12. What volume of diluent (assume sterile water) is
needed to make an isotonic solution from 0.45 g of
sodium chloride?
a. 25 mL
b. 50 mL

c.
d.

Pharmaceutical Calculations

100 mL
125 mL

13. The ratio strength of a solution is 1:900 (w/v).


What is the percent weight by volume [(w/v)%] of
the solution?
a. 0.1%
b. 1.1 %
c. 0.9%
d. 9%
14. The ratio strength of a solution is 1:5000 (w/v).
What is the percent weight by volume [(w/v)%] of
the solution?
a. 0.02%
b. 2 %
c. 0.8%
d. 8%
15. A vial of tobramycin sulfate contains 40 mg of drug
per mL of injection. A patient was given 0.5 mL.
How much tobramycin sulfate was administered?
a. 10 mg
b. 20 mg
c. 30 mg
d. 40 mg
16. How many days will the following prescription supply?
Rx
Penicillin VK suspension 250 mg/5 mL
Sig. 1 tsp. qid t.a.t. disp 200 mL
a. 7 days
b. 10 days
c. 14 days
d. 21 days
17. A medication is available in a 200 mg/5 mL vial. An
Rx calls for 150 mg bid  10d.
How many milliliters are needed for a single day?
a. 5 mL
b. 7.5 mL
c. 10 mL
d. 75 mL
18. A medication is available in a 200 mg/5 mL
multiple-use vial. An Rx calls for 300 mg
bid  10d.
How many vials are needed for the full course?
a. 15 vials
b. 30 vials
c. 60 vials
d. 75 vials
19. JK is a 42 year-old woman who has a prescription for
32 mEq of oral potassium chloride. However, your
pharmacy only has 600 mg controlled-release
potassium chloride tablets in stock. How many
tablets are required each day to provide this dose?
(MW 75)
a. 8
b. 3
c. 2
d. 4
e. 6

10

SECTION I

PHARMACEUTICAL PRACTICE

20. If a patient has a temperature of 102.2 F, what is the


patients temperature in degrees Celsius?
a. 37.6  C
b. 38.4  C
c. 39  C
d. 40.1  C
21. If 500 mL of a 15% (v/v) solution of methyl salicylate
in alcohol is diluted to 1500 mL, what will be the
percentage strength (v/v)?
a. 225%
b. 5%
c. 45%
d. 0.45%
22. A medication is available in a 150 mg/5 mL vial.
An Rx calls for 300 mg bid  10d.
How many mL are needed for a single dose?
a. 5 mL
b. 10 mL
c. 50 mL
d. 100 mL
23. What is the day supply for this prescription?
Amoxicillin 125 mg/5 ml (100 ml)
SIG: ss tsp tid
a. 2 days
b. 100 days
c. 25 days
d. 13 days
e. 10 days
24. What is the percent weight by volume [%(w/v)] if
250 grams of dextrose is dissolved in 300 mL of
water to make a final volume of 500 mL?
a. 4.5%
b. 5%
c. 45.45%
d. 50%
25. If a prescription reads Dispense: XVIII capsules,
how many capsules should be dispensed?
a. 12 tablets
b. 18 tablets
c. 22 tablets
d. 30 tablets
26. What total quantity of tablets should be dispensed
for the following prescription?
Rx: Prednisone 5 mg
Sig: 10 mg qid  2 days
10 mg tid  2 days
10 mg bid  2 days
5 mg tid  2 days
5 mg bid  2 days Then stop.
Qty qs
a. 23 tablets
b. 25 tablets
c. 46 tablets
d. 50 tablets
27. What quantity should be dispensed for the following
prescription?

Rx: Prednisone 10 mg
Sig: 2 tabs bid  3 days
1 tab bid  3 days
1 tab qd  3 days
1/2 tab qd  3 days Then stop.
Qty qs
a. 9 tablets
b. 10 tablets
c. 22 tablets
d. 23 tablets
28. How many grams of NaCl are there in
1000 mL of D5W/0.45% NaCl solution?
a. 4.5 g
b. 0.6 g
c. 0.45 g
d. 0.25 g
29. How many grams of dextrose are in 1000 mL of D5W/
0.45% NaCl solution?
a. 100 g
b. 50 g
c. 20 g
d. 15 g
30. How many grams of dextrose are in 500 mL of a 10%
dextrose solution?
a. 500 g
b. 50 g
c. 150 g
d. 200 g
31. How many grams of NaCl are in 500 mL of 0.9%
sodium chloride (NS) solution?
a. 5 g
b. 2.5 g
c. 4.5 g
d. 1.5 g
32. How many milligrams of neomycin are in 25 mL of a
1% neomycin solution?
a. 250 mg
b. 125 mg
c. 400 mg
d. 500 mg
33. How many grams of amino acids are in 500 mL of a
5% amino acid solution?
a. 2.5 g
b. 22.5 g
c. 25 g
d. 50 g
e. 10 g
34. A pharmacist has 25 mL of 0.5% gentian violet
solution. What will be the final ratio strength if he
or she dilutes this solution to 600 mL with purified
water?
a. 1:8
b. 1:200
c. 1:500
d. 1:1000
e. 1:4800

CHAPTER 2

Pharmaceutical Calculations

35. An order is written for 1 g of lidocaine in 250 mL of


D5W to infuse at 60 mg/hr. What is the correct
infusion in (mL/hr)?
a. 15 mL/hr
b. 20 mL/hr
c. 35 mL/hr
d. 45 mL/hr

43. How many milliliters contain 2.5 g of


cephalothin if the concentration of the solution
is 1 g/4.5 mL?
a. 16.5 mL
b. 13.5 mL
c. 14.25 mL
d. 11.25 mL

36. An order is written for 25,000 units of heparin in


250 mL of D5W to infuse at 17 mL/hr. How many
units of heparin will the patient receive in
6 hours?
a. 10,200 units
b. 40,000 units
c. 10,800 units
d. 20,400 units

44. How many grams of iodine are in 4 mL of a 50%


iodine solution?
a. 1 g
b. 2 g
c. 3 g
d. 4 g

37. An order calls for 2.5 million units of aqueous


penicillin. How many milliliters are needed if the vial
concentration is 500,000 units/mL?
a. 6 mL
b. 2 mL
c. 10 mL
d. 5 mL
38. How many milliliters are needed for 5 million units
of penicillin if the vial concentration is 1 million
units per mL?
a. 15 mL
b. 5 mL
c. 10 mL
d. 20 mL
39. Valproic acid syrup comes in a 250 mg/5 mL
concentration. How many mg are present in 7.5 mL
of solution?
a. 1000 mg
b. 500 mg
c. 375 mg
d. 250 mg
40. How many milliliters of 250 mg/5 mL valproic acid
syrup are needed for a 0.5-g dose?
a. 1 mL
b. 5 mL
c. 10 mL
d. 15 mL
41. If a drug comes in a 250 mg/1.5 mL solution, how
many milliliters are required for a 2 g dose?
a. 1.5 mL
b. 2 mL
c. 4.5 mL
d. 6 mL
e. 12 mL
42. How many grams of ampicillin are in 3 mL of a
500 mg/1.5 mL solution?
a. 1 gram
b. 4 grams
c. 3.5 grams
d. 2 grams

11

45. How many milliliters of a 50% dextrose solution are


needed for a 7.5-g dextrose dose?
a. 7.5 mL
b. 10 mL
c. 15 mL
d. 20 mL
46. How many grams of sodium are in 50 mL D5W
solution?
a. 0
b. 1
c. 2.5
d. 3
47. The unit of weight measurement that is the
same in both the apothecaries and avoirdupois
systems is the?
a. Dram
b. Grain
c. Ounce
d. Pound
e. Scrupple
48. One microgram equals one thousand (1000):
a. Centigrams
b. Grams
c. Kilograms
d. Nanograms
e. Milligrams
49. Calculate the drip rate for 120 mL of IV fluids to be
given over a half hour via an IV set that delivers
15 gtt/mL.
a. 13 gtt/min
b. 25 gtt/min
c. 60 gtt/min
d. 33 gtt/min
e. 50 gtt/min
50. If a patient is given IV fluids at a rate of 25 gtt/min
over 1 hour, how much fluid will be administered?
The drop factor is 15 gtt/ml.
a. 50 mL
b. 100 mL
c. 125 mL
d. 200 mL
e. 225 mL

12

SECTION I

PHARMACEUTICAL PRACTICE

51. In order to achieve better pain control, codeine


phosphate 0.7 mL SC  1 is ordered for a patient.
The injectable form of codeine phosphate is
available in a concentration of 50 mg/mL. How much
codeine will this patient receive in this dose?
a. 20 mg
b. 30 mg
c. 35 mg
d. 60 mg
e. 100 mg
52. Morphine is ordered for a patient, and the nurse
gives him 1.9 mL from a vial with a concentration of
40 mg/2.5 mL. How much morphine was the patient
given?
a. 5 mg
b. 10 mg
c. 20 mg
d. 30 mg
e. 40 mg
53. The vial of hydromorphone that you have in stock
has a concentration of 1.5 mg/0.5 mL. If the patient is
given 0.7 mL, how much hydromorphone did she
receive?
a. 1. 8 mg
b. 2.1 mg
c. 2.2 mg
d. 2.4 mg
e. 3 mg
54. What is the concentration (in percent) of a solution
containing 20 mEq of potassium chloride per 15 mL
of liquid? (MW 75)
a. 10
b. 15
c. 20
d. 25
e. 2.5
55. Diazepam is to be administered by the IV route
to an adult patient. It is given at a rate of 5 mg/min
over 90 seconds. How much diazepam is given to this
patient?
a. 5 mg
b. 6 mg
c. 7.5 mg
d. 8 mg
e. 10 mg
56. How many milligrams of morphine were given to a
patient who received 6.2 mL of a 5 mg/mL solution?
a. 31 mg
b. 22 mg
c. 25 mg
d. 35 mg
e. 46 mg
57. A nurse wants to give 300 mcg of levothyroxine
IV to a patient, from a vial containing 0.4 mg/mL.
How many milliliters should be given to
the patient?

a.
b.
c.
d.
e.

0.6 mL
0.8 mL
1.0 mL
1.2 mL
7.5 mL

58. A patient is to take 2.6 mL of oral furosemide, and


each teaspoon contains 40 mg. How much
furosemide will the patient be taking in their 2.6 mL
dose?
a. 20.8 mg
b. 40 mg
c. 33.1 mg
d. 16.5 mg
e. 24 mg
59. What is the percent weight=weight (%[w/w]) if
250 grams of dextrose is dissolved in 300 mL of
water to make a final volume of 500 mL?
a. 4.5%
b. 5%
c. 45.45%
d. 50%
60. According to USP specifications, how many
milligrams is equal to 1/2 grain?
a. 64.8 mg
b. 32.4 mg
c. 32.4 g
d. 3.24 mg
61. If the adult dose of a drug is 200 mg, what is the
estimated dose for a child with a BSA of 0.8 m2, using
the BSA estimation method?
a. 92 mg
b. 150 mg
c. 50 mg
d. 75 mg
62. If Lanoxin Pediatric Elixir contains 0.1 mg of
digoxin per mL, how many mcg of digoxin are
in 6 mL elixir?
a. 6 mcg
b. 60 mcg
c. 600 mcg
d. 6000 mcg
63. What is the percentage of alcohol in a mixture of
200 mL of 95% v/v alcohol, 1000 mL of 70% v/v
alcohol, and 200 mL of 80% v/v alcohol?
a. 75%
b. 82%
c. 0.75%
d. 7.5%
64. A TPN order requires 500 mL of D5W. How many
mL of D50W should be used if the D5W is not
available?
a. 450 mL
b. 550 mL
c. 50 mL
d. 25 mL

CHAPTER 2

65. How much sodium chloride is needed to make the


following prescription isotonic given E value for zinc
sulfate is 0.15?
Zinc sulfate 2%
Sodium chloride q.s.
Purified water q.s 60 mL
a. 540 mg
b. 1200 mg
c. 180 mg
d. 360 mg
66. How much elemental iron is present in 500 mg
of ferrous sulfate (FeSO4  7H2O) with atomic
weights are Fe 55.9; sulfur 32.1; oxygen 16.0;
and hydrogen 1.0. Iron has valences of
2 and 3)?
a. 100.5 mg
b. 167.7 mg
c. 111.8 mg
d. 120 mg
67. What will be the final ratio strength of a solution if
one wishes to dilute 100 mL of 0.5% gentian violet
solution to 1250 mL with purified water?
a. 1:500
b. 1:1000
c. 1:2500
d. 1:5000
68. How many beclomethasone (Qvar) inhalers should
be dispensed to provide a 90-day supply? The
recommended dose is 168 mcg BID. The commercial
inhaler delivers 42 mcg per metered dose and
contains 200 inhalations
a. 2 inhalers
b. 3 inhalers
c. 4 inhalers
d. 5 inhalers
69. If 6.25 g of boric acid are dissolved in sufficient
alcohol to make a total volume of 100 mL, what is the
strength of boric acid in the solution in mg/mL?
a. 62.5 mg/mL
b. 6.25 mg/mL
c. 625 mg/mL
d. 62.5 g/mL
70. If 50 mL of 4% (w/v) Xylocaine solution are added
to 100 mL bag of D5W injection, what is the
percentage strength (w/v) of Xylocaine in the final
product?
a. 1%
b. 2.5%
c. 1.3%
d. 2%
71. A blood glucose reading shows 200 mg% of glucose.
Express this value in mg/mL.
a. 0.2 mg/mL
b. 20 mg/mL
c. 2 mg/mL
d. 200 mg/mL

Pharmaceutical Calculations

13

72. How many grams of solute are there in 250 g of a


1:50 w/w solution?
a. 50 g
b. 5 g
c. 0.5 g
d. 5 mg
73. How many milligrams of drug are there in 50 mL of a
5% w/v solution?
a. 0.25 g
b. 5 g
c. 2500 mg
d. 250 mg
74. How many milligrams of drug are there in 100 g of a
1:200 w/w mixture?
a. 500 mg
b. 5 mg
c. 5 g
d. 5000 mg
75. How many mg of sodium bicarbonate (NaHCO2)
contain 400 mg of sodium?
a. 1496 mg
b. 1.496 mg
c. 0.922 mg
d. 922 mg
76. What is the percentage (based on weight) of Na in
Na2CO3?
a. 21.7%
b. 43.4%
c. 4.34%
d. 0.434%
77. How many milligrams of sodium chloride are there
in a 2 mmol solution? (MW of NaCl 58.5)
a. 117 mg
b. 11.7 mg
c. 1.17 mg
d. 1.17 g
78. How many millimoles of calcium fluoride are present
in 5 g? (MW of calcium fluoride 78)
a. 0.641 mmol
b. 6.41 mmol
c. 64.1 mmol
d. 64.1 mol
79. How many grams of KCl are needed to prepare
50 mmols solution? (MW of KCl 74.6)
a. 3730 mg
b. 37.30 mg
c. 3.730 g
d. 37.30 g
80. What is the percentage strength of 1:200 solution
of oil in alcohol?
a. 0.5% v/v
b. 0.005% v/v
c. 5% v/v
d. 0.5 mL

14

SECTION I

PHARMACEUTICAL PRACTICE

81. What is the percentage concentration of a 2:2000


solution of benzalkonium chloride?
a. 0.01% w/v
b. 1% w/v
c. 0.1% w/v
d. 10% w/v
82. To make 100 mL of 1:1000 w/v solution, how many
milligrams of NaHCO2 are needed?
a. 10 mg
b. 100 mg
c. 0.1 mg
d. 1 mg
83. If the reorder point for simvastatin 40 mg is 2 and
the maximum is 5, how many bottles should be
ordered if there is 1 bottle of simvastatin 40 mg?
a. 0
b. 1
c. 4
d. 5
84. You have a bottle of 1 g amoxicillin powder for
oral suspension. How many mL of purified water
are needed to prepare a 125 mg/5 mL suspension?
a. 10 mL
b. 1.0 mL
c. 40 mL
d. 4.0 mL
85. How much dilutant needs to be added to a 500 mg vial
of Merrem to obtain a concentration of 50 mg/mL?
a. 1 mL
b. 5 mL
c. 10 mL
d. 50 mL
e. 100 mL
86. A patient is to receive 1000 mL of solution over
8 hours. If the administration set delivers 20 gtt/mL,
at how many gtt/min should the solution be
infused?
a. 4 gtt/min
b. 20 gtt/min
c. 40 gtt/min
d. 0.4 gtt/min
87. A solution is to be administered by IV infusion at a
rate of 100 mL/hr. How many gtt/min should
be infused if the administration set delivers
20 drops/mL?
a. 5 gtt/min
b. 50 gtt/min
c. 3.3 gtt/min
d. 33 gtt/min
88. A patient is to receive 1 L of a normal saline by IV
infusion over 12 hours. What is the rate of infusion
expressed as gtt/min if the infusion set delivers 20
gtt/mL?
a. 28 gtt/min
b. 2.8 or 3 gtt/min

c.
d.

28 gtt/hr
280 gtt/hr

89. An IV infusion for a 22-lb child calls for 4 mcg/kg/min


at a rate of 1.2 mL/hr. How many milligrams of a drug
are required in a 100-mL infusion solution to supply
the required dose?
a. 440 mg
b. 200 mg
c. 3.3 mg
d. 20 mg
90. If 100 g dextrose is dissolved in 100-mL water to
make a final volume of 150 mL, what is the %w/v of
this solution?
a. 50% w/v
b. 66.7%w/v
c. 5% w/v
d. 6.67% w/v
91. What is the %w/v concentration of a 100 mL of
amoxicillin oral suspension containing 150 mg/5 mL?
a. 30% w/v
b. 1.5% w/v
c. 3% w/v
d. 15% w/v
92. If a patient has a temperature of 37 C, what is the
patients temperature in Fahrenheit?
a. 69 F
b. 100 F
c. 98 F
d. 98.6 F
93. If a solution has a ratio strength of 1:10000 w/v, what
is the % w/v of the solution?
a. 0.01% w/v
b. 1.0% w/v
c. 0.1% w/v
d. 10% w/v
94. The required dose for a 110-lb patient is 0.5 mg/kg/min.
If the concentration of the medication is 1 g/100 mL,
what is the infusion rate in mL/hr?
a. 2.5 mL/min
b. 25 mL/min
c. 150 mL/hr
d. 15.0 mL/hr
95. If 2.54 g of a drug is used to make 1000 tablets,
roughly how many milligrams will 60 tablets
contain?
a. 25 mg
b. 50 mg
c. 100 mg
d. 150 mg
e. 200 mg
96. What is the %w/w of 1000 mL solution when 200 g
dextrose is dissolved in 900 mL of water?
a. 18.2%
b. 20%

CHAPTER 2

c.
d.

1.82%
2.0%

97. A 16 oz. 10 g/15 mL lactulose bottle contains how


many tablespoon-doses?
a. 96 doses
b. 3.2 doses
c. 320 doses
d. 32 doses
98. If the required dose is 1 tsp bid, how long will an
180-mL bottle of clemastine fumerate syrup
0.5 mg/5 mL last?
a. 36 days
b. 18 days
c. 30 days
d. 60 days
99. How many milligrams of prochlorperazine are in a
5 mL injection containing 5 mg/mL?
a. 5 mg
b. 1 mg
c. 10 mg
d. 25 mg
100. The recommended daily adult dose of a medication
is 2 mg/kg body weight in 4 divided doses. What is
the daily dose for a person weighing 110 lb?
a. 100 mg daily
b. 25 mg daily
c. 220 mg daily
d. 10 mg daily
101. Kefzol is ordered at a dose of 30 mg/kg/day divided
three times daily for an elderly female patient who
weighs 88 lbs. How much Kefzol will be given to her
daily?
a. 400 mg
b. 800 mg
c. 1200 mg
d. 1.5 g
e. 1 g

Pharmaceutical Calculations

15

104. An IV bag with 1250 mL of IV fluids is to be infused


over 3 hours with a 15 gtt/mL set. How many
milliliters will be infused over each hour?
a. 300 mL/hr
b. 345 mL/hr
c. 416 mL/hr
d. 427 mL/hr
e. 458 mL/hr
105. A 240 lb male patient is prescribed zidovudine at a
dose of 2 mg/kg three times daily. How much
zidovudine will this patient receive daily?
a. 218 mg
b. 436 mg
c. 654 mg
d. 245 mg
e. 186 mg
106. A patient weighing 155 lbs is ordered dobutamine at
a rate of 5 mcg/kg/min. When the drug is admixed,
200 mg of dobutamine was put into a 500 mL bag of
normal saline (NS). What is the final concentration
of the solution in mcg/mL?
a. 5 mcg/mL
b. 40 mcg/mL
c. 200 mcg/mL
d. 400 mcg/mL
e. 444 mcg/mL
107. The required dose of Drug X for a 150-lb patient is
1 mg/kg/min. If the concentration of the medication
is 5 g/100 mL, what is the infusion rate in mL/hr?
a. 2.1 mL/min
b. 5 mL/min
c. 82 mL/hr
d. 400 mL/hr
108. What is the milliosmolarity of normal saline (0.9%
NaCl) solution? Na23, Cl35.5
a. 145 mOsm/L
b. 220 mOsm/L
c. 255 mOsm/L
d. 285 mOsm/L
e. 308 mOsm/L

102. How much Kefzol would have to be drawn up from


the vial and injected into an IV bag to make one dose
of Kefzol for the patient in question 101? The vial
you have on hand was compounded to a
concentration of 325 mg/mL.
a. 5.45 mL
b. 6.25 mL
c. 1.65 mL
d. 1.23 mL
e. 0.68 mL

109. If a solution contains 1 g of sodium chloride dissolved


in 100 mL of D5W, how many milliosmoles are
present? (Na 23; Cl 35.5; hydrous dextrose 198)
a. 60
b. 120
c. 240
d. 300
e. 360

103. A bag with 250 mL of NS will be infused over 2 hours


using a microdrip set (60 gtt/mL). What is the flow
rate in drops per minute?
a. 60 gtt/min
b. 100 gtt/min
c. 115 gtt/min
d. 125 gtt/min
e. 140 gtt/min

110. An order is received in the pharmacy for an irrigation


solution of 0.25% w/v acetic acid. The acetic acid in
stock is 99.9% w/w, and must be added to 128 oz of
purified water. How many grams of 99.9% w/w acetic
acid must be added to the purified water in order to
prepare the final irrigation solution?
a. 6.7
b. 8.2

16

SECTION I

c.
d.
e.

PHARMACEUTICAL PRACTICE

9.6
10.8
12.3

111. One gram of a given chemical is soluble in 10 mL of


alcohol. What is the specific gravity of alcohol if a
saturated solution is made with this chemical into
an 11.1% w/w solution?
a. 0.75
b. 0.8
c. 0.9
d. 1.0
e. 1.15
112. How many grams of iodine are consumed
daily from 0.3 mL tid of 5% w/v strong iodine
solution?
a. 450
b. 45
c. 4.5
d. 0.045
e. 0.0045
113. A technician is preparing a potassium chloride
infusion for a hypokalemic patient. The IV bag
contains 250 mL of normal saline and 5.86 g of KCl
(KCl molecular weight 74.6). In the final infusion
preparation, how many milliequivalents of
potassium chloride are present?
a. 12.7 mEq
b. 78.5 mEq
c. 43.7 mEq
d. 22.5 mEq
e. 36.4 mEq
114. What is the volume of distribution of a drug with
a clearance of 9 L/hr, F 50, and an elimination half
life of 7.8 hours?
a. 70 L
b. 93 L
c. 101 L
d. 149 L
115. How many mL of tetracycline suspension 250 mg/
5 mL must be given in order for the patient to
receive 150 mg?
a. 3 mL
b. 6 mL
c. 12 mL
d. 7.5 mL
e. 15 mL
116. An acidic drug has a pKa of 5.4. What percentage of
the drug is ionized in urine with a pH of 6.0?
a. 25.1%
b. 74.9%
c. 20.1%
d. 79.9%
117. A weakly basic drug has a pKa of 8.6. What percent
would be un-ionized in circulation?
a. 0.059%
b. 0.941%

c.
d.

5.9%
94.1%

118. A patient is to receive 2 mg/min of labetalol


hydrochloride that has been prepared by adding
200 mg of labetalol hydrochloride injection to 250 mL
of D5W to attain a final concentration of 2 mg/3 mL.
How many milliliters per hour should the nurse
infuse?
a. 2.5 mL/h
b. 150 mL/h
c. 3 mL/h
d. 180 mL/h
119. A patient is to receive 4 L of D5NS over 24 hours. If
the IV tubing has a drip factor of 15 gtt/mL, what is
the drip rate?
a. 18 gtt/min
b. 42 gtt/min
c. 55 gtt/min
d. 250 gtt/min
120. What is the day supply for this prescription?
Persantine 25 mg (quantity 100) SIG: 1 tab qod
a. 200
b. 100
c. 50
d. 25
e. 20
121. Which erythromycin salt(s) is/are available by
IV infusion?
I. Erythromycin lactobionate
II. Erythromycin stearate
III. Erythromycin ethylsuccinate
a.
b.
c.
d.
e.

I only
II only
I and II
I and III
II and III

122. The hydrogen ion concentration of a topical solution


is 1  108. What is the pH of this solution?
a. 8
b. 4
c. 2
d. 6
e. None of the above
123. A 3-mEq/mL solution of KCl contains how many
milligrams per milliliter? (MW of KCl 74.5)
a. 0.04 mg/mL
b. 24.8 mg/mL
c. 111.8 mg/mL
d. 223.5 mg/mL
124. A patient is prescribed 10 mEq KCl once daily to
compensate for the potassium wasting effects of
furosemide. How many mg of KCl is in each dose?
(MW of KCl 74.5)
a. 3.73 mg
b. 7.45 mg

CHAPTER 2

c.
d.

372.5 mg
745 mg

125. CH is a 72-year-old woman who requires empiric


vancomycin treatment for pneumonia. She is 50
200 and weighs 125 lbs. Her SCr is 1.2 mg/dL. What is
her calculated creatinine clearance?
a. 33.5 mL/min
b. 39.4 mL/min
c. 38.0 mL/min
d. 44.7 mL/min
126. JW is a 64-year-old man with a prior medical history
positive for hypertension and poorly controlled
diabetes. He presents to the ED today complaining
of fever and chills that have progressively worsened
over the last 24 hours. His physical exam is
unremarkable with the exception of an oozing foot
ulcer. The medical team wants to begin empiric
antibiotic treatment including an aminoglycoside.
What is his calculated creatinine clearance? (height
50 800 , weight 247 lbs, SCr 1.1 mg/dL)
a. 61.3 mL/min
b. 55.8 mL/min
c. 65.6 mL/min
d. 107.8 mL/min
127. A patients labs show serum calcium of 8.7 mg/dL
and serum albumin of 3.2 g/dL. What is her
corrected calcium concentration?
a. 8.7 mg/dL
b. 9.34 mg/dL
c. 8.06 mg/dL
d. 14.46 mg/dL
128. How many milliliters of water should be added to
100 mL of a 1:125 (w/v) solution to obtain a solution
such that 25 mL diluted to 100 mL will yield a 1:4000
strength solution?
a. 300 mL
b. 400 mL
c. 500 mL
d. 600 mL
e. 700 mL
129. Using the following WBC and differential, calculate
this patients absolute neutrophil count (ANC).
WBC: 2.0  103/mm3
Segs: 14.8%
Bands: 5%
Lymphocytes: 55%
Monocytes: 22%
Eosinophils: 1.7%
Basophils: 1%
a. 99/mm3
b. 196/mm3
c. 396/mm3
d. 540/mm3

Pharmaceutical Calculations

17

130. What is the pH of a buffer solution containing 0.25 M


of acetic acid and 0.75 M of sodium acetate? (Ka
1.75  10-5)
a. 3.87
b. 4.28
c. 5.24
d. 6.53
131. A drug is available as both a 150-mg tablet and
100 mg capsule. The AUC for the tablet was
calculated to be 76.3 mg.hr/L and for the capsule
84.2 mg.hr/L. What is the relative bioavailability of
the tablet with respect to the capsule?
a. 0.61
b. 0.73
c. 0.91
d. 1.37
132. If a person is 138 pounds and 66 inches, what is their
BMI (Body mass index) (kg/m2)?
a. 46
b. 22.2
c. 2.2
d. 703
e. 12.5
133. TJ is a 23-year-old woman who has a long history of
poorly controlled asthma. She is admitted to the
hospital with a severe asthma attack is is started on
aminophylline. She is currently receiving a
continuous infusion of aminophylline at 40 mg/hour.
The patient has not experienced any adverse effects
and is responding well to therapy. Her steady-state
theophylline concentration is 12.6 mg/mL. What
dose of oral theophylline sustained-release
formulation may she be converted to?
a. 600 mg q12h
b. 400 mg q12h
c. 200 mg q12h
d. 800 mg q12h
e. None of the above
134. What statement is true regarding first order
kinetics?
I. Drug is metabolized at a rate that is constant
overtime.
II. Aspirin is metabolized through first order
kinetics.
III. V Vmax [C]/km
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II and III

..................................................

Compounding

CHAPTER

...................................................................................................................................................................

The Federal Drug Administration (FDA) defines traditional


pharmacy compounding as the combining, mixing, or
altering of ingredients to create a customized medication
for an individual patient in response to a licensed
practitioners prescription (www.fda.gov). Compounding
is often used when the patient is intolerant of a
manufactured drug. It may also be needed when an
alternative route of administration is needed and not
available commercially. It also allows physicians to
prescribe customized strengths and dosage systems.
I. Regulation
The FDA established current Good Manufacturing
Practices (cGMP) to ensure that minimum standards are
met for drug product quality. The National Association of
Boards of Pharmacy (NABP) formulated Good
Compounding Practices that are used by many states.
These can be found in the United States PharmacopeiaNational Formulary (USP-NF) and establish standards for
extemporaneous compounding of nonsterile and sterile
preparations.
II. Quality assurance
A. Nonsterile products1: The following questions are
to be considered carefully before compounding:
1. Have the physical and chemical properties and
medicinal, dietary, and pharmaceutical uses of
the drug substances been reviewed?
2. The first time a product was compounded, was
documentation made of the materials and
equipment used, method of mixing, labeling
requirements, and dating determination?
3. Are the quantity and quality of each active
ingredient identifiable?
4. Will the active ingredients be effectively
absorbed, locally or systemically according to
the prescribed purpose, from the preparation
and route of administration?
5. Are there added substances, confirmed or
potentially present from manufactured
products, that may be expected to cause an
allergic reaction, irritation, toxicity, or
undesirable organoleptic response from the
patient? Are there added substances, confirmed
or potentially present, that may be unfavorable
(e.g., unsuitable pH or inadequate solubility)?
6. Were all calculations and measurements
confirmed to ensure that the preparation will be
compounded accurately?
7. Were expiration dates of all compounding
materials being used checked?
8. Are there clear labeling and directions?
18

9. Are there instructions regarding proper


handling and storage of the medication?
10. Does it look or smell like it should?
B. Sterile products
1. Check compatibilities between drug-vehicle,
drug-drug, and drug-container.
2. The finished product should be free of
contamination, such as particles, bacteria,
pyrogens.
3. All compounding materials should be checked
for expiration date and proper function before
use.
4. The solution should be clear, with all drugs
completely in dissolution.
5. Final products should have seals or appropriate
closures to indicate that the product has not
been contaminated or manipulated since it was
compounded and that it was checked and
verified by the pharmacist so that nothing is
added to the final product.
6. Clear labeling and directions should be present.
7. Labeling and instructions for proper
handling and storage of medication should be
present.
8. Logs/documentation/lot numbers should be
present.
III. Requirements for Compounding
A. Materials
B. Equipment
1. Beaker
2. Biologic safety cabinet
3. Flask
4. Mortar
5. Ointment slab
6. Pestle
7. Scale
8. Stirring rod
9. Syringe/needle
10. Weighing paper/weighing boat
11. Spatula
C. Compounding area
1. The product may be flammable (e.g., alcohol),
highly reactive (e.g., phenol), or cytotoxic (e.g.,
chemotherapy). The pharmacist may need to
prepare the medication in a vertical flow hood to
prevent harm to himself/herself. The pharmacist
should use appropriate attire (e.g., gloves,
gowns, facial covering).
IV. Achieving Stabilization of the Preparation
A. Temperature

CHAPTER 3

B.
C.
D.
E.

V.

pH
Stability and degradation
Shelf life
Special handling of product while in transport/
delivery (e.g., do not shake)
F. Precipitation
G. Exposure to light and air
H. Storage
1. Glass bottles for certain medications to avoid
adhesion to plastic, such as nitroglycerin in
polyvinyl chloride (PVC) bags, and to avoid the
release of plastic contaminants in the
medication
2. Refrigeration or freezing to prevent drug
degradation or microbial growth
3. Light-resistant container to prevent photo
degradation
Compounded Preparations
A. Solutions
 A liquid preparation in which the ingredients
are completely soluble
B. Suspensions
 A liquid preparation in which the particles are
mixed with but remain undissolved in a fluid or
solid. Note: contents generally settle to the
bottom of the bottle, so shake well before
dispensing, and the patient should shake the
item well prior to each use.
C. Emulsions
 Emulsions are two-phase systems that consist of
two immiscible liquids, one of which is uniformly
dispersed throughout the other as fine droplets.
They are classified as oil-in-water (o/w) or waterin-oil (w/o).There may also be multiple emulsions
(e.g. w/o/w emulsion where a water droplet
enclosed in an oil droplet is itself dispersed in
water). They may be used internally to mask the
bitter taste or odor of drugs or externally as
creams or lotions.
D. Capsules
 Solid dosage forms in which medicinal and/or
inert substances are closed in a hard or soft
gelatin shell.
E. Molded Tablets
 Also known as tablet triturates, the preparation
of tablets by molding has been replaced by
tablet compression. Molded tablets dissolve
rapidly in the mouth and do not contain
disintegrants, lubricants, or any other
component that slows the rate of dissolution.
F. Wafers
 An oral dosage form consisting of a case,
usually of rice-flour paste, containing the
medication
G. Troches
 A solid dosage form that is meant to be sucked,
not swallowed, for drug absorption; also known
as a lozenge
H. Suppositories
 A suppository is a medicine that melts after
insertion into the rectum (rectal suppository),
the vagina (vaginal suppository), or the
urethra (urethal insert)
I. Parenteral preparations

Compounding

19

 Desired effect is systemic when substance is

given by routes other than the digestive tract.


Parenteral administration generally has the
greatest bioavailability because it avoids an
absorption phase and possible inactivation by
first-pass metabolism by the liver. It can be
further divided into two subgroups: parenteral
by injection or infusion and other nonoral
parenteral administration (transdermal patch)
J. Powders
 Used internally or externally, powders are often
mixed with water or other liquid solvent
K. Creams, ointments, gels
 Cream: A water-based preparation that is waterwashable
 Ointment: An oil-based preparation that is not
water-washable
 Gel: Semisolid systems consisting of
suspensions of small inorganic particles or
large organic molecules interpenetrated by a
liquid
L. Tincture
 A solution of a medicinal substance in an
alcoholic or hydroalcoholic solvent
VI. Examples of References Pharmacists May Use for
Compounding
A. The United States PharmacopeiaNational
Formulary (USPNF): The compendium for
pharmaceutical medicines and excipients for use
in the United States
B. Trissels Stability of Compounded Formulations:
The handbook of stability and compatibility of
injectable products
C. International Journal of Pharmaceutical
Compounding
D. Drug Facts and Comparisons
E. Material Safety Data Sheets (MSDSs)
F. USP 797 Guidebook to Pharmaceutical
Compounding: Sterile Preparations.

Excipients
Binders

Buffer

Coatings

Coloring
agents
Diluents/
Fillers

Keep ingredients together, particularly in tablets


Example: candelilla wax, corn starch
Maintain the pH of a product
to prevent drug degradation and
can also protect the user from GI
irritation
Example: disodium hydrogen phosphate,
sodium bicarbonate
Can protect the drug product from
degradation from the environment
or from the GI tract for long-acting
or delayed-release
Example: gelatin, ethyl cellulose
Generally used to match flavor
Example: FD & C Red 40, tartrazine (FD&C
#5)
Allow for filling of a capsule or
increase the size of a tablet for
greater ease in handling; also used
for creating aliquots or dissolving
medications

20

SECTION I

PHARMACEUTICAL PRACTICE

Example: magnesium stearate, anhydrous calcium phosphate


Promote solubility of one liquid into
another
Example: methyl cellulose, glyceryl
monostearate
Make a drug product more palatable
Example: cherry syrup
Reduce bacterial growth or protect
the drug
Example: benzyl alcohol, butyl paraben
Prevent oxidation of active substances
Example: ascorbic acid, sodium
metabisulfite
Used as solubilizing agent or preservative (not for use in infants or
epidurals)
Example: benzyl alcohol
Type of preservative
Example: methlparaben, propylparaben
Complex heavy metals, can improve
efficacy of antioxidants or
preservatives
Examples: citric acid, tartaric acid,
ethylenediamine-tetraacetic
acid sodium (EDTA)
Offset the poor taste of a product
Example: sorbitol, simple syrup

Emulsifiers

Flavoring
agents
Preservatives

Antioxidants

Alcohols

Parabens
Chelators

Sweeteners

Infusion (herbal
medicine)
Infusion
(modern
medicine)
Least
measurable
quantity

Levigate

Liniment

Mortar
Muddle

Pestle
Spatulation

Topical

Transdermal

Compounding Terms
Aliquot

Aseptic
technique

Biologic safety
cabinet

Eutectic mixture

Geometric
dilution

A stock product made for a quantity


below the least measurable
quantity; see also least
measurable quantity
The process of making a sterile
product while reducing
contamination of any particles,
pathogens, or pyrogens;
particularly important for
parenteral, ophthalmic, and
inhaled preparations
A work area designed to
aseptically prepare sterile
medications; the vertical flow
hood is ideal for preparing
chemotherapeutic drugs,
volatile substances, and
other cytotoxic medications;
the horizontal flow
provides no protection to
the user
The combination of two solid
substances at room
temperature, which become
liquid when combined
Mixing two powders of unequal size

Triturate

The steeping of a medicine in


water; making a tea
Continuous delivery of a solution
over a prolonged period of time
The smallest amount that can be
quantified by a scale or other
measuring device; if a quantity
must be used for which the
device cannot measure, an
aliquot must be made
To make into a smooth, fine
powder or paste, as by grinding
when moist
A liquid or semifluid preparation
that is applied to the skin as a
counterirritant
A bowl for grinding and mixing
ingredients
The process of grinding a solid in a
mortar with a pestle into a fine
powder
A rod used to grind and mix
ingredients
Blending small amounts of powder
by movement of a spatula on a
paper or tile
A dosage form meant to treat an
affected area without systemic
effects
A medicated adhesive patch that is
placed on the skin to deliver a
time-released dose of medication
through the skin and into the
bloodstream; not to be confused
with a topical medication
To rub, crush, grind, or pound into
fine particles or a powder;
pulverize; also known as
muddling

Reference
1. Schnatz RG: Pharmaceutical Compounding Nonsterile
Drug Products, USP33-NF28 Online. Chapter 795,
Proposed 2010 revision.

REVIEW QUESTIONS
(Answers and Rationales on page 317.)
1. What is the percent weight/weight (w/w) if 250 grams
of dextrose is dissolved in 300 mL of water to make a
final volume of 500 mL?
a. 4.5%
b. 5%
c. 45.45%
d. 50%

CHAPTER 3

2. How many days worth of medication is provided by


the following prescription?
Penicillin VK suspension 250 mg/5 mL
Sig tsp i qid tat disp 200 mL
a. 7 days
b. 10 days
c. 14 days
d. 21 days
3. What volume was dispensed by the pharmacist if the
percent concentration (weight/volume) of cefaclor
was 3.7%?
Cefaclor oral suspension 187 mg/5 mL
Sig 1 tsp bid
a. 50 mL
b. 75 mL
c. 100 mL
d. 150 mL
4. To prepare a 2% w/w hydrocortisone cream,
how many grams of pure hydrocortisone
powder must be mixed with 30 g of 1%
hydrocortisone cream?
a. 0.31 g
b. 3.1 g
c. 1.5 g
d. 15 g
5. What is the final concentration (w/w) of zinc
oxide ointment when 200 g of a 5% zinc oxide
ointment and 400 g of a 10% zinc oxide ointment
are mixed?
a. 7.5%
b. 0.83%
c. 8.3%
d. 83%
6. A pharmacist is asked to compound a 200 mL
mixture containing maldroxyl 50 mL,
diphenhydramine elixir 50 mL, and viscous lidocaine
2%. How much viscous lidocaine 2% is needed to
prepare the order?
a. 200 mL
b. 4 mL
c. 100 mL
d. 60 mL
7. A pharmacist is trying to make 10% w/w sodium
chloride solution and has 1 lb of 28% w/w sodium
chloride solution on hand. How many grams of 10%
w/w sodium chloride solution can be made from the
amount on hand?
a. 65
b. 127
c. 684
d. 1271
e. 1582
8. A pharmacist is to prepare 500 g of an ointment
containing 5% w/w glycerin. The density of glycerin is

Compounding

21

1.25 g/mL. How many milliliters of glycerin are


needed to prepare this formulation?
a. 6.8 mL
b. 7.3 mL
c. 8.4 mL
d. 9.1 mL
e. 20 mL
9. A pharmacist wants to prepare 4 L of 10% w/v
hydrochloric acid from a stock bottle of 36.8% w/w
hydrochloric acid (specific gravity 1.19). How
many milliliters of the stock solution should be used
to prepare the final 10% w/v hydrochloric acid
solution?
a. 125
b. 243
c. 512
d. 815
e. 913
10. A compounding pharmacy gets an order for 2 lb of 2%
mupirocin ointment. The stock ointment on hand is
5% mupirocin ointment. How many grams of the 5%
formulation should be mixed with white petrolatum
in order to prepare this order?
a. 14
b. 85
c. 127
d. 243
e. 363
11. How much ointment would fit into 80 2-oz jars?
a. 80 oz
b. 4 lb
c. 875 g
d. 10 lb
e. 1271 g
12. For a 7-year-old female patient:
Sodium fluoride 500 mcg
M & Ft cap DTD # LX
Sig 1 qd
How many grams of sodium fluoride are required to
prepare the prescription?
a. 0.5
b. 30
c. 50
d. 0.03
e. 0.05
13. Sodium fluoride 250 mcg
M & Ft cap DTD # LX
Sig 1 qd
How many milligrams of sodium fluoride are required
to prepare the prescription?
a. 0.25
b. 15
c. 25
d. 150
e. 250

22

SECTION I

PHARMACEUTICAL PRACTICE

14. What problem(s) should the pharmacist anticipate in


preparing this prescription?
I. Caustic nature of sodium fluoride
II. Poor water solubility of sodium fluoride
III. Difficulty in weighing small quantity of powder
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

15. For a 23-year-old female patient:


Diphenhydramine 50 mg
Acetaminophen 325 mg
M & Ft cap DTD # XXX
Sig 1 qhs
Lactose will be the preferred filler agent because of
its solubility. The appropriate capsule size for the
above prescription will be capsule size #1 with an
approximate capacity of 0.5 mL. The tapped density
of the ingredients are as follows: diphenhydramine
800 mg/mL, acetaminophen 850 mg/mL, and lactose
950 mg/mL. Determine the amount of lactose needed
to prepare this prescription.
a. 52.4 mg
b. 111.8 mg
c. 1.57 g
d. 3.35 g
e. Cannot be determined
16. Which of the following is true regarding emulsions?
I. One-phase systems
II. May be used internally or externally
III. May be classified as oil-in-water or water-in-oil
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

17. Which of the following statements about laminar flow


hoods are FALSE?
I. Laminar flow hoods provide clean air to the
working area.
II. Laminar flow hoods provide a constant flow of air out
of the work area to prevent room air from entering.
III. The air flowing out from the hood suspends and
removes contaminants introduced into the work
area by personnel.
IV. The room air is taken into the HEPA filter and
is then passed through a different filter to remove
gross contaminants, such as lint or dust.
a.
b.
c.
d.
e.

I only
III only
II and III only
I, II, and III
IV only

18. Objects in the hood are arranged in a manner to get


full benefit of the laminar flow of air. In a horizontal
hood, the items should be placed:

a.

b.

c.
d.

individually left to right, equidistance from


the front and back of the laminar airflow
hood working space as well as from each
other
grouped left to right, equidistance from the
front and back of the laminar airflow hood
working space
individually back to front, equidistance from
each other
grouped on only one side of the hood

19. Which of the following is NOT available as largevolume parenterals (LVP)?


a. Dextrose and sodium chloride injection USP
b. Mannitol injection USP
c. Lactated Ringers injection USP
d. Sodium chloride injection USP
e. None of the above
20. Which of the following statements about laminar flow
hoods are FALSE?
I. Laminar flow hoods provide clean air to the
working area.
II. Laminar flow hoods provide a constant flow of air
out of the work area to prevent room air from
entering.
III. The room air is taken into the HEPA filter and is
then passed through a different filter to remove
gross contaminants such as lint or dust.
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

21. To remove 5 mL of solution from a 30-mL multidose


vial, what is the correct order of steps?
I. Place point of syringe needle onto the vials
rubber closure at a 45 angle with the bevel
opening facing upwards.
II. Inject the air.
III. Draw 5 mL of air into the syringe.
IV. Raise the needle angle to 90 and insert needle
through the rubber closure.
V. Remove 5 mL of solution.
a.
b.
c.
d.
e.

I, II, III, IV,


III, I, IV, II,
III, IV, I, II,
I, III, IV, II,
I, III, II, IV,

V
V
V
V
V

22. To maintain sterility, what part(s) of the syringe


should never be touched?
I. Luer-lok tip
II. Plunger
III. Barrel
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

CHAPTER 3

23. Needle size is determined by the gauge and the


length. Which of the following statements are correct?
I. The larger the gauge number, the larger the
diameter of the needles bore.
II. The larger the gauge number, the finer the
diameter of the needles bore.
III. Needle length is measured in inches.
IV. Needle length is measured in centimeters.
V. Needle length is measured in millimeters.
a.
b.
c.
d.
e.

I and III
I and IV
I and V
II and III
II and V

24. A concentrated vancomycin solution of 10 mL is


added to a 100 mL piggyback bag of normal saline.
The solution is to be infused over one hour. What is
the infusion rate?
a. 10 mL/hr
b. 100 mL/hr
c. 110 mL/hr
d. 200 mL/hr
e. 210 mL/hr
25. How many milliliters of water should be mixed with
120 mL of syrup containing 75% w/v sucrose to make
a syrup containing 50% w/v sucrose?
a. 60 mL
b. 80 mL
c. 100 mL
d. 120 mL
e. 200 mL
26. Which of the following statements is INCORRECT?
a. To prevent contamination, swab rubber closure
of the vial with 70% alcohol using firm strokes in
any direction or manner.
b. To prevent core formation, insert needle to
penetrate the rubber closure at same point with
both tip and heel of bevel.
c. To prevent vacuum formation, inject an
equal amount of air for the volume of fluid to be
removed.
d. When reconstituting drug powder, remove an
equal amount of air for the volume of diluent
added.
e. None of the above.
27. Which of the following statements about pyrogens is/
are CORRECT?
I. Pyrogens are bacterial endotoxins.
II. Pyrogens are metabolic products of living
microorganisms.
III. Pyrogens cause a pyretic response upon
injection.
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

Compounding

23

28. Which of the following is NOT a method used to


sterilize pharmaceutical products?
a. Steam
b. Dry heat
c. Filtration
d. Gas
e. All of the above are used to sterilize products
29. True or False: When preparing a dose from an
ampule, one should use a 0.22-mm inline filter rather
than the 5-mm filter straw.
a. True
b. False
30. True or False: Nitroglycerin should always be
prepared in glass because it is adsorbed to polyvinyl
chloride (PVC), the plastic in the bags, and
intravenous (IV) tubing.
a. True
b. False
31. Drugs that are adsorbed to the inner lining of IV
containers and tubing or administration sets, resulting
in loss of drug delivered to the patient, include:
I. Nitroglycerin
II. Insulin
III. Heparin
a.
b.
c.
d.
e.

I only
II only
I and II
III only
I, II, and III

32. Which of the following is not an example of an


irrigation solution?
a. Neomycin and polymyxin B sulfates
b. Ringers solution
c. Sodium chloride
d. Dextrose
e. Sterile water
33. Which of the following is a common base for ointments?
a. Bentonite
b. Methylcellulose
c. VEEGUM 6%
d. Hydrophilic petrolatum
e. All of the above
34. Answer the question based on the following
prescription:
For a 7-year-old patient:
Omeprazole 10 mg/tsp
Sig 1 tsp q day, dispense 200 mL
Recipe:
Dissolve omeprazole in sodium bicarbonate 8.4%
200 mL
When preparing the above recipe, the pharmacist
should be concerned with which of the following?
I. The purpose of sodium bicarbonate 8.4%
II. The absence of alcohol
III. The acid-base reaction between sodium
bicarbonate 8.4% and gastric acid

24

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

I and II only
III only
II and III only
I, II, and III
None of the above

35. Answer the question based on the following


prescription:
For a 7-year-old patient:
Omeprazole 10 mg/tsp
Sig 1 tsp q day, dispense 200 mL
Recipe
Dissolve omeprazole in sodium bicarbonate 8.4%
200 mL
Using the information given in the prescription and
the recipe above, what is the final concentration for
this oral suspension?
a. 0.05 mg/mL
b. 0.67 mg/mL
c. 2 mg/mL
d. 200 mg
e. 400 mg
36. Answer the question based on the following
prescription:
For a 7-year-old patient:
Omeprazole 10 mg/tsp
Sig 1 tsp q day, dispense 200 mL
Recipe
Dissolve omeprazole in sodium bicarbonate 8.4%
200 mL
What is the amount of omeprazole required for this
prescription?
a. 10 mg
b. 20 mg
c. 40 mg
d. 200 mg
e. 400 mg
37. Medicinal agents can either be weak acids or weak
bases. Weak bases include the following EXCEPT:
I. codeine.
II. diphenhydramine.
III. phenobarbital.
a.
b.
c.
d.
e.

I only
II only
III only
I and II
I and III

38. Burows solution 15 mL


White petrolatum 45 g
Sig Apply bid AM and hs
The % w/v expression is commonly used as an
abbreviation for percent weight in volume for
solutions or suspensions of solids in liquids. What is
the meaning of 2% w/v?
a. 2 mg/100 mL
b. 2 mg/1 L
c. 2 g/100 mL
d. 2 g/1 L
e. 0.02 g/100 mL

39. Please refer to the following prescription:


Rx
Starch
Talc aa 5 g
Lanolin 10 g
Petrolatum qs ad 60 g
What amount of starch should be weighed?
a. 1 g
b. 5 g
c. 15 g
d. 45 g
e. Cannot be determined
40. Which of the following statements is FALSE?
a. Water for injection, USP, is purified by distillation
or by reverse osmosis.
b. Water for injection, USP, meets the same
standards for the presence of total solids as
purified water, USP.
c. Water for injection, USP, may not contain added
substances.
d. Water for injection, USP, must be both sterile and
pyrogen free.
e. Sterile water for injection, USP, is used for
reconstitution of antibiotics.
41. Limewater is commonly used interchangeably for:
a. aluminum acetate.
b. hydrogen peroxide.
c. aluminum subacetate.
d. coal tar solution.
e. calcium hydroxide.
42. Which of the following best describes wool fat?
a. Oleaginous
b. Absorption (anhydrous)
c. Emulsion (water-in-oil [w/o] type)
d. Emulsion (oil-in-water [o/w] type)
e. Water soluble
43. Which of the following best describes hydrophilic
ointment?
a. Oleaginous
b. Absorption (anhydrous)
c. Emulsion (W/O type)
d. Emulsion (O/W type)
e. Water soluble
44. Which of the following best describes Lubriderm
products?
a. Oleaginous
b. Absorption (anhydrous)
c. Emulsion (W/O type)
d. Emulsion (O/W type)
e. Water soluble
45. Which of the following best describes Eucerin
products?
a. Oleaginous
b. Absorption (anhydrous)
c. Emulsion (W/O type)
d. Emulsion (O/W type)
e. Water soluble

CHAPTER 3

Compounding

25

46. For an 8-year-old female patient:


Rx
Sodium fluoride 250 mcg
M & Ft cap DTD # XC
Sig 1 qd
How many milligrams of sodium fluoride are required
to prepare this prescription?
a. 2.75
b. 22.5
c. 25
d. 27.5
e. 225

51. Which of the following statements is/are true for a


vertical flow hood?
I. Air blows towards worker.
II. Air blows from top down to maintain sterility and
protect the worker.
III. It is used to make chemotherapy.

47. Needle size is determined by the gauge and the length.


Which of the following statements is/are correct?
I. The larger the gauge number, the larger the
diameter of the needles bore.
II. The larger the gauge number, the finer the
diameter of the needles bore.
III. Needle length is measured in inches.

52. Lactose, microcrystalline cellulose, and starch are


commonly used:
I. as a diluent or filler.
II. to provide bulk.
III. to provide cohesion to the powder blend of
active and inactive components for transfer into
capsule shells.

a.
b.
c.
d.
e.

I only
III only
I and II only
II and III
I, II, and III

48. When obtaining a 3-mL dose from a 5-mL ampule,


which one of the following steps is INCORRECT?
a. Disinfect the neck of the ampule using an alcohol
swab.
b. Leave the swab in place.
c. Break ampule neck by snapping neck toward the
back wall of the laminar flow hood and away from
you.
d. Place needle tip into solution while holding the
ampule almost horizontally.
e. After drawing approximately 4 mL of solution,
aspirate excess into alcohol swab.
49. If the infusion rate for drug X is 120 mL/hr, what is the
infusion rate in drops (gtt) per minute if drug X is
administered using an infusion set that delivers
20 gtt/mL?
a. 20 gtt/min
b. 40 gtt/min
c. 60 gtt/min
d. 80 gtt/min
e. 100 gtt/min
50. The pharmacist needs to prepare 100 capsules, each
containing 4 mg of estriol and 0.5 mg of estradiol.
A size 3 capsule is chosen for the prescription and
separate capsules are filled with drug and lactose.
Weights of contents are as follows: estriol 250 mg,
estradiol 180 mg, lactose 300 mg
How much of each ingredient are needed to prepare
this prescription.
a. 100 mg estriol; 50 mg estradiol; 32.54 g lactose
b. 200 mg estriol; 50 mg estradiol; 20.7 g lactose
c. 300 mg estriol; 100 mg estradiol; 63.7 g lactose
d. 400 mg estriol; 50 mg estradiol; 29.637 g lactose
e. 500 mg estriol; 100 mg estradiol; 15.2 g lactose

a.
b.
c.
d.
e.

a.
b.
c.
d.
e.

I only
III only
I and II only
II and III
I, II, and III

I only
III only
I and II only
II and III only
I, II, and III

53. The total fill weight (drug plus excipients) for one
capsule of a prescription was determined to be
280 mg. Which of the following choices is/are
appropriate?
a. #1 capsule
b. #3 capsule
c. #2 capsule
d. #5 capsule
e. b or c
54. Question refers to the following prescription:
An 18-year-old female patient
Room No. 1827
Theophylline 200 mg
Potassium chloride 10 mEq
D5W 250 mL
Infuse over 4 h at 0800, 1400, 2000 for 4 days
How many vials of theophylline injection (25 mg/mL,
20 mL per vial) are needed to complete this order for
4 days?
a. 3
b. 4
c. 5
d. 6
e. 7
55. Question refers to the following prescription:
An 18-year-old female patient
Room No. 1827
Theophylline 200 mg
Potassium chloride 10 mEq
D5W 250 mL
Infuse over 4 h at 0800, 1400, 2000 for 4 days
A pharmacist reviewing this order should:
a. call the prescriber to inform of a drug interaction
between theophylline and potassium chloride.

26

SECTION I

b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

call the prescriber because the dose of


theophylline is too low.
talk to the IV room technician to make sure the IV
is put in a light-blocking bag.
call the prescriber and inform that potassium
chloride is not compatible in D5W.
fill the prescription as is.

56. Sintering is:


a. a method of mixing in a mortar and pestle.
b. a process of steeping and soaking a substance.
c. a method of extraction by boiling disolved
chemicals.
d. a process in which powdered materials are
heated to form a coherent mass.
57. Which of the following is/are considered by USP-NF to
be tablet and/or capsule lubricants?
I. Magnesium stearate
II. Sodium benzoate
III. Sodium lauryl sulfate
a.
b.
c.
d.
e.

I only
II only
III only
I and III
All of the above

58. Which of the following are considered by USP-NF to


be antimicrobial preservatives?
I. Methylparaben
II. Sodium benzoate
III. Alcohol
a.
b.
c.

I only
II only
I and II

d.
e.

I and III
All of the above

59. How many grams of coal tar must be incorporated


into 450 grams of zinc oxide paste to prepare a 10%
coal tar ointment?
a. 10 g
b. 45 g
c. 50 g
d. 90 g
e. 95 g
60. A 0.22-mm filter is able to remove which of the
following from a parenteral solution?
I. Glass particles from an ampule
II. Bacteria
III. Viruses
a.
b.
c.
d.
e.

I only
II only
I and II
II and III
All of the above

61. An order is written for 60 mL of 0.5% (w/v) lidocaine


hydrochloride solution. The pharmacy has 2% (w/v)
lidocaine hydrochloride solution in stock. To fill this
order, how many milliliters of normal saline (NS)
should the pharmacist mix with what volume of
lidocaine stock solution?
a. 5 mL 2% solution and 55 mL NS
b. 15 mL 2% solution and 45 mL NS
c. 55 mL 2% solution and 5 mL NS
d. 45 mL 2% solution and 15 mL NS

..................................................

Drug Information Resources

4
CHAPTER

....................................................................................................................................................................

The pharmacist is the healthcare professional who is the


point-person for all drug information. Because it is
impossible for any one person to know everything, the
pharmacist should be able to know where to get
information. In addition to locating the information, the
pharmacist must be able to interpret, evaluate, and apply it.
Equally important is communication of this information.
If a physician asks for information, the pharmacist can
likely share the information with the language in which it
was discovered. However, if the information is intended
to be passed along to a patient, the pharmacist may
need to explain it in a way that reflects the patients health
literacy (explained in further detail in Chapter 6,
Patient Education).
I. Hierarchy of Pharmacy and Medical Literature
A. Primary
1. Original journal articles
2. Case reports
3. Descriptive reports
4. Expert communication
5. Unpublished literature
6. Peer-reviewed journals
a) New England Journal of Medicine
b) Journal of the American Medical Association
(JAMA)
c) Annals of Internal Medicine
7. Nonpeer-reviewed journals
a) Supplements
b) Throw away journals
8. Advantages
a) Most timely
b) Provides vital information on which
therapeutic decisions are based
9. Disadvantages
a) Cost (e.g., cost of journal subscriptions)
b) Access
c) Inconsistencies (e.g., conflicting journal
articles)
d) Requires basic statistic knowledge to
interpret study design and results
B. Secondary
1. Abstracting and indexing systems of primary
literature
2. Medline
3. EMBASE
4. International Pharmaceutical Abstracts (IPA)
5. Advantages
a) Organizes volumes of literature

II.

b) Versatile
c) IPA is a more pharmacy-specific database
6. Disadvantages
a) Cost (e.g., EMBASE is more than
$40,000/year)
b) Access
c) Scope (some systems may search more or
different journals so not always
comprehensive)
7. Medline
a) Abstracting service created by National
Library of Medicine
b) Uses MeSH (Medical Subject Headings)
terms
c) PubMed is a free search engine for accessing
Medline
C. Tertiary (Table 4-1)
1. Assembled information or interpretations of
primary literature
2. Textbooks
3. Drug compendia
4. Full-text electronic books and databases
5. Review articles
6. Internet sources of various levels of reliability:
It is critical to educate patients about web
sources that provide misinformation.
7. Advantages
a) Access
b) Compactness
c) Conciseness
d) Cost
e) Ease of use/easy to read
8. Disadvantages
a) Timeliness
b) Errors in transcription
c) Incomplete detail
Components of a Clinical Trial
A. Population
1. Sample: subset of the population
a) Individuals from whom data are collected for
the study
2. Sample size/power analysis
a) Determination of the number of patients
required to adequately power a study
(1) A large sample size can detect a small
difference.
(2) A small sample size can detect a large
difference.

27

28

SECTION I

Table 4-1

PHARMACEUTICAL PRACTICE

Common Examples of Tertiary Literature (NOTE: lists are not comprehensive)

Topic of Interest

Literature in which to Find Topic

Alcohol/sugar/gluten free
Adverse effects

Red Book (Drug Topics)


Meylers Side Effects of Drugs
Drug-Induced Diseases
Orange Book (electronic version on FDA website)
Remingtons Pharmaceutical Sciences
Extemporaneous Formulations
USP DI Vol II: Advice for the Patient (obsolete)
Clinical Pharmacology
Lexi-Comp
Micromedex
Websites:
www.drugdigest.org
www.webmd.com
Cecil Textbook of Medicine
Harrisons Principles of Internal Medicine
AHFS Drug Information
Clinical Pharmacology
Drug Facts and Comparisons
Micromedex
Harriet Lane Handbook (pediatric)
Drugs in Pregnancy and Lactation (Briggs)
Drug Prescribing in Renal Failure
Hansten and Horn Drug Interaction Analysis and Management
Clinical Pharmacology
Drug Facts and Comparisons
Micromedex
Index Nominum
Martindale: The Complete Drug Reference
Trissels Handbook on Injectable Drugs
Kings Guide to Parenteral Admixtures
Natural Standard
Natural Medicines Comprehensive Database
Goodman and Gilmans The Pharmacologic Basis of Therapeutics
Pharmacotherapy: A Pathophysiologic Approach (DePiro)
Applied Therapeutics: The Clinical Use of Drugs (Koda-Kimble)
IDENTIDEX (Micromedex)
IDENT-A-DRUG
WebMD
Clinical Pharmacologys Drug Identifier
Drug Facts and Comparisons
Micromedex
USP DI Volume 1 (obsolete)
AHFS Drug Information
Clinical Pharmacology
www.cdc.gov

Bioequivalence
Compounding
Consumer health information

Diseases/General Medicine
Dosing
Dosing: Special populations

Drug Interactions

Foreign Drug Identifications


IV Compatibility
Natural Products
Pharmacology/Pharmacokinetics

Tablet Identification

Unlabeled use

Vaccines

3. Randomization
a) Blocked
b) Stratified
c) Cluster
d) Systematic assignment
B. Baseline assessment
C. Study location
1. Single center: use of one site to conduct a
research study
2. Multicenter: use of multiple sites to conduct a
research study

3. International: use of multiple countries to


conduct a research study
D. Blinding
1. Single blind: patient masked, or investigator
masked, but not both
2. Double blind: patient and investigator masked
3. Open label: no masking; all patients and
investigators aware of treatment
E. Controls
1. Placebo controlled: administration of an
inactive substance for a control

CHAPTER 4

2. Double dummy: use of multiple controls to


maintain blinding
a) Example: To compare two medicines, one
presented as blue tablets and one as red
capsules, researchers could also supply blue
placebo tablets and red placebo capsules so
that both groups of patients would take one
blue tablet and one red capsule
3. Active control: use of an established therapy as
the comparative group
4. Crossover: patients serve as their own control
by receiving multiple interventions
F. Methods
G. Institutional review board (IRB), ethics committees
H. Intervention, duration of treatment
I. Monitoring
J. Follow-up
K. Compliance
1. Measure of adherence
L. Outcome Measures
1. Primary/secondary endpoints
2. Surrogate endpoints: easily measured
substitute markers in place of more clinically
meaningful endpoints (e.g., CD4 count used as a
surrogate endpoint for a trial regarding HIV
infection)
M. Statistics
1. Goal: to be confident that the probability
statement (p value) is valid and to maximize the
possibility of detecting a difference when one
actually exists1
N. Results
O. Reporting adverse effects (MedWatch)
III. Assessing Trial Results
A. Findings related to primary outcomes
1. What type of data are presented?
a) Categorical (qualitative data)
(1) Nominal: named categories (e.g., blood
type, gender, race)
(a) Mutually exclusive
(2) Ordinal: ordered categories of data; often
sequenced (e.g., poor, good, excellent)
(a) Mutually exclusive
b) Numerical (quantitative data)
(1) Continuous: ordered, sequenced, and has
a set of distance or values between rank
(e.g., blood pressure, glucose levels)
B. Were the findings statistically significant?
1. Hypothesis testing
a) Tests against the null hypothesis
(1) Null hypothesis (Ho): states that the
variable of interest is equal to a given
value or that no relationship exists
between various variables
2. Statistical and clinical significance
a) Statistical: probability that the results are due
to chance or due to a true effect of treatment
b) Clinical: importance of the practical relevance
or variation of a difference in outcomes
(1) A statistically significant outcome may
not be clinically significant
3. P value
a) The probability of the observed result or a
more extreme result occurring by chance alone

Drug Information Resources

29

b) The probability of the observed difference


occurring if the null hypothesis is true
4. Types of error
a) Type I error (false-positive error)
(1) Rejecting the null hypothesis when it
should be accepted
(2) Relates to validity
(3) Alpha level
(a) It is the risk of finding a difference
when there is not one (risk of
experiencing a type I error)
(b) Usually 5% by designation,
indicating there is a less than 5%
possibility that a finding is due to
chance (does not really exist)
b) Type II error (false-negative error)
(1) Accepting the null hypothesis when it
should have been rejected (there was a
difference that was not detected)
(2) Relates to power
(3) Beta level
(a) The chance researchers are willing
to risk that a difference will not be
detected
(b) The probability of committing a
Type II error
(c) Type II error (or beta)
(d) Usually 20% by designation
5. Confidence interval (CI)
a) The range of values in which researchers can
be certain that the true point estimate will
fall
b) 95% CI most commonly reported
(1) 95% probability that the true result lies
within the range of results found, and
there is a 5% probability that the true
range lies outside the interval
c) CI is calculated by subtracting from and
adding to the sample mean the appropriate
number of standard errors of the mean
d) The narrower the CI, the greater the
reliability and more precise the data
C. How large is the treatment effect (when the
primary outcome shows a statistically significant
difference)?
1. Relative risk (RR)
a) The reduction in the risk from one therapy
relative to another (RR events in treatment
group  events in placebo group)
(1) A RR of 1 means that there is no
difference.
(2) A RR that is <1 (e.g., 0.75) means that
risk is decreased
(3) A RR that is >1 (e.g., 1.15) means that
risk is increased
b) Commonly used to express the therapeutic
benefit of a drug
2. Absolute reduction risk (ARR)
a) The absolute difference between the
probabilities of the treatment event rate and
control event rate (ARR Probability of
events in placebo group [PB]  Probability
of events in the active treatment group [PA])
b) Expressed as a percentage

30

SECTION I

PHARMACEUTICAL PRACTICE

3. Number needed to treat (NNT)


a) Number of subjects needed to treat over a
defined period of time to experience one
benefit of therapy
b) NNT 1/ARR
IV. Evaluating Clinical Trials
A. Questions to consider
1. Why was this study conducted?
2. Were previous trials conducted?
B. Consider the power/significance of the study
1. Statistically
2. Clinically
C. Critique the trial
1. Population
2. Intervention
3. Endpoints: were they appropriate?
4. Statistics
a) Consider the appropriateness of each
statistical test and result
D. Can the findings from this study be extrapolated to
patient/consumer?
V. Study Types in Clinical Research
A. Randomized controlled trial
1. An experiment in which investigators assign, by
random allocation, eligible subjects into
intervention groups to receive or not to receive
one or more interventions that are being
compared
2. Gold standard: Randomized controlled trials are
considered to have the highest validity and
reliability of various research designs, as they
eliminate causes of bias and provide a high
level of experimental control.
3. Necessary for Food and Drug Administration
(FDA) approval
B. Cohort studies
1. Group of subjects who have not yet
experienced the outcome of interest
2. Subjects exposed to a factor of interest are
compared to a group not exposed and followed
prospectively over time
C. Case-control studies
1. Subjects with a particular characteristic are
compared to a similar group without the
characteristic to determine the cause
2. Retrospective
D. Case reports
1. No control
2. No designed intervention
3. Descriptive account of a subject
E. Meta-analysis
1. A method of combining results of previous and
similar research to determine a single estimate
of treatment
F. Cross-sectional studies
1. Measurements taken at a single point in time
G. Survey
1. Research used to study the incidence,
distribution, and relationship
H. N-of-1 trials
1. Randomized controlled study involving a single
subject
2. Crossover design
3. Lack of generalizability to a population

VI. Research involved in the FDA Drug Approval Process


A. Preclinical research
1. Goal: assess potential therapeutic effects
2. Does not predict human response
B. Phase I
1. Initial study, usually in healthy human volunteers
2. Small number of subjects (fewer than 100
subjects); brief length of study (less than 1 year
3. Determines toxicology, metabolism, and
pharmacologic activities; early evidence of
effectiveness
C. Phase II
1. Expanded drug study to obtain preliminary
efficacy data and safety in humans
2. Small and highly homogeneous population
of patients for whom the drug is intended
(N several hundred participants)
D. Phase III
1. Pivotal trials
2. Larger study (N hundreds to thousands of
participants)
3. Long-term (up to several years)
4. Semidiverse population (representing target
population)
5. Establishes final formulation, marketing claims,
product stability, packaging, and storage concerns
6. Successful completion may mean ready to
submit compound to FDA for approval
E. Phase IV (postmarketing surveillance)
F. New Drug Application (NDA) form
G. Abbreviated NDA (aNDA) form: generic drug
approval
H. Supplemental NDA (sNDA): approval for new
indication

Reference
Haney MS, Meek PD: Essential clinical concepts of
biostatistics, Kansas City, 1999, ACCP.

REVIEW QUESTIONS
(Answers and Rationales on page 320.)
1. A customer requests a recommendation for a
reliable brand for ginseng. To ensure that she gets a
ginseng product that has been tested for quality,
what website(s) should a pharmacist consult?
I. ConsumerLab.com
II. ConsumerReports.org
III. American Society of Health-System Pharmacists
(ASHP) Essentials
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

2. A customer requests a recommendation for a


reliable brand for honeysuckle. To ensure that she
gets a honeysuckle product that has been tested for
quality, a pharmacist should NOT consult which of
the following websites?
a. ConsumerLab.com
b. ConsumerReports.org

CHAPTER 4

c.
d.
e.

www.USP.org
www.nsf.org
www.fda.gov

3. How is Drug Facts and Comparisons organized?


a. Alphabetically by generic name
b. Alphabetically by manufacturer name
c. By imprint code
d. By therapeutic use
e. None of the above
4. How is Trissels Handbook of Injectable Drugs organized?
a. Alphabetically by generic name
b. Alphabetically by manufacturer name
c. By imprint code
d. By therapeutic use
e. None of the above
5. In which of the following resources could you have
found information on unlabeled uses for a drug?
I. Lexi-Comp
II. Drug Facts and Comparisons
III. United States Pharmacopeia (USP) Volume 1
(obsolete)
a.
b.
c.
d.
e.

I only
II only
I and II only
II and III only
I, II, and III

6. Which of the following resources would you NOT use


to identify a drug?
a. IDENTIDEX System
b. Clinical Pharmacology
c. Facts and Comparisons eAnswers
d. WebMD
e. Natural Standard
7. In which resource would you find separate age,
height, and weight charts for boys and girls?
I. Drugs in Pregnancy and Lactation (Briggs)
II. Harriet Lane Handbook
III. NeoFax
a.
b.
c.
d.
e.

I only
II only
III only
I and II only
I, II, and III

8. The FDAs MedWatch is a service through which one


can report:
I. product quality problems.
II. product use errors.
III. adverse reactions.
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

9. Any original published research in regards to a


medication is considered to be:

a.
b.
c.

Drug Information Resources

31

primary literature.
secondary literature.
tertiary literature.

10. Where would you best find a list of sound-alike lookalike drugs?
a. AHFS
b. EMBASE
c. IPA
d. MEDLINE
e. Institute for Safe Medication Practices (ISMP)
11. True or False: PubMed requires the use of MeSH terms.
a. True
b. False
12. If given a PMID, what is the quickest way to locate
the article?
a. Micromedex
b. EMBASE
c. PubMed
d. Ovid
13. Why is it difficult to detect new or rare adverse drug
reactions (ADR)?
a. It is not mandated to report ADRs to a program
such as MedWatch.
b. Patients are taking too many medications to
determine which causes an ADR.
c. Patients are poorly monitored while on therapy.
d. Patients are hesitant to report an ADR.
14. True or False: Because MedWatch is an FDA program
and not a manufacturer, MedWatch does not publish
safety-related drug labeling changes.
a. True
b. False
15. What do P and T in P & T Committee stand for?
a. Pharmacy and Therapeutics
b. Pharmacology and Therapeutics
c. Pharmacy and Times
d. Pharmacy and Toxicology
16. True or False: The P & T Committee, like the IRB,
reviews, monitors, and has the authority to approve
or disapprove research.
a. True
b. False
17. A recent formulary protocol has taken effect at your
hospital and the proton pump inhibitor (PPI) of
choice is Prilosec (omeprazole). The clinical
pharmacist receives a prescription for Protonix
(pantoprazole) and automatically switches to
Prilosec. This is an example of:
a. generic substitution.
b. pharmaceutical alternative.
c. pharmaceutical equivalence.
d. therapeutic interchange.
18. Which of the following are disadvantages in
retrospective data collection?
a. There is no impact on clinical outcome.

32

SECTION I

b.
c.
d.

PHARMACEUTICAL PRACTICE

There are limited resources.


It is time consuming.
All of the above.

19. Results of a study show that, compared with placebo,


the investigational agent decreases blood pressure by
10 mm Hg with p value of 0.006. What is the best
description of this result?
a. Statistically significant and clinically significant
b. Statistically significant but not clinically significant
c. Clinically significant but not statistically
significant
d. Not clinically significant and not statistically
significant
20. Which of the following are limitations of clinical
studies to detect adverse effects?
a. ADR studies use healthy, nonsymptomatic
patients.
b. ADR studies use a relatively small sample size
when compared to the numbers of patients
estimated to be prescribed a drug.
c. ADR studies use a relatively short study duration
when compared to the duration of treatment
used for most chronic medications.
d. All of the above.
e. None of the above.
21. Type A adverse drug reactions:
I. are usually dose-dependent and predictable.
II. are unrelated to pharmacological actions.
III. are caused by immunological mechanisms.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

22. A type of data analysis in which the results of several


studies are lumped together and analyzed refers to
which type of study?
a. Randomized controlled study
b. Cohort study
c. Case study
d. Meta-analysis
23. The outcome measure of a study comparing the
efficacy of a new sepsis drug with existing therapy is
mortality at 28 days. What is this type of outcome?
a. Surrogate measure
b. Primary outcome measure
c. Secondary outcome measure
d. None of the above
24. The primary outcome measure for a study comparing
the efficacy of a new sepsis drug with existing therapy
is mortality at 28 days. What type of data is this
outcome?
a. Continuous
b. Ordinal
c. Nominal
d. None of the above

25. Which source contains information regarding foreign


drugs?
a. Martindale: The Complete Drug Reference
b. Red Book Drug Topics
c. Lexi-Comp
d. AHFS Drug Information
26. Which of the following people are blinded in a tripleblind study?
I. Statistician
II. Investigators
III. Experimental subjects
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

27. Which of the following is the form to report adverse


drug reactions to the FDA?
a. Naranjo Causality Scale
b. Vaccine Adverse Event Reporting System (VAERS)
c. MedWatch
28. The statistical analysis of a large collection of analysis
results from individual studies for the purpose of
integrating the findings. This definition refers to what
type of study?
a. Meta-analysis
b. Randomized controlled trial
c. Crossover study
d. Case-control study
e. Cohort study
29. To achieve the least amount of bias, what study
design should be used?
a. Open label
b. Single blind
c. Double blind
30. Which type of error is made if the researcher
concludes that there is difference between the
studied groups when there is NO difference?
a. Type II error
b. Type I error
c. Both a and b
d. None of the above
31. True or False: MEDLINE is the database that is
available to anyone free of charge.
a. True
b. False
32. What type of literature is readily available in most
pharmacies?
a. Primary literature
b. Secondary literature
c. Tertiary literature
33. The National Institutes of Health and the National
Library of Medicine worked to develop what online
drug information database?

CHAPTER 4

a.
b.
c.
d.
e.

DailyMed
Clinical Pharmacology
Medscape Drug Reference
Natural Standard
UptoDate

34. What is currently the name for the PDA counterpart


of Micromedex?
a. DailyMed
b. Clinical Pharmacology
c. mobileMicromedex
d. Epocrates
e. Thomson mobile
35. Through which of the following is MEDLINE available
free to the public?
a. Blackwell Synergy
b. EBSCOHost
c. EMBASE
d. OVID
e. PubMed
36. The truncation symbol for PubMed is:
a. #
b. $
c. *
d. &
e.
37. The primary function of the Peer Review Process
is to:
a. Reduce subscription costs
b. Ensure accuracy and quality of content
c. Increase the journal revenues via reviewer fees
d. Advance the publication process
e. Decrease the number of research papers
submitted for publication
38. A nurse working on the pediatric unit of a hospital
incorrectly administers 3 units of regular insulin to a
child intramuscularly rather than subcutaneously.
The nurse is at fault for a(n):
a. Vaccine scheduling error
b. Immunization injury
c. Medication error
d. Adverse drug event
e. All of the above
39. A girl enters your pharmacy and asks you to identify a
drug she found in her boyfriends gym bag. The
ethical principle that would prohibit you from
providing the answer is:
a. Autonomy
b. Equality
c. Sincerity
d. Privacy
e. None of the above
40. Copyright Law is a subsection of which of the
following laws?
a. Criminal Law
b. Administrative Law
c. Civil Law

d.
e.

Drug Information Resources

33

Intellectual Property Law


None of the above

41. Which of the following is an example of continuous data?


a. Gender
b. NHYA class
c. Blood pressure
d. Mortality
42. Copying words or ideas without giving credit for
the original idea or language is referred to as:
a. Plagiarizing
b. Copyrighting
c. Broadcasting
d. Referencing
e. Reproducing
43. A unique alphanumeric string assigned to an object
such as an electronic journal article is a(n):
a. Digital Object Identifier (DOI)
b. HyperTextMarkup Language (HTML)
c. Extensible markup locator (XML)
d. Uniform Resource Identifier (URI)
e. HyperText Transfer Protocol (HTTP)
44. Which of the following resources may be used to
check the compatibility of a drug with other drugs?
I. Trissels Handbook of Injectable Drugs
II. Kings Guide to Parenteral Admixtures
III. Drug-Induced Diseases
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

45. Any undesirable effect associated with the use of a


drug at a normal dose is referred to as a(n):
a. Adverse drug reaction
b. Medication error
c. Medication misadventure
d. All of the above
e. None of the above
46. Which of the following is most likely to be an example
of primary literature?
a. A chapter in Harrisons Principles of Internal
Medicine entitled Womens Health
b. A monograph in Natural Standard Database
entitled Saw Palmetto
c. A journal entitled The Annals of
Pharmacotherapy
d. An article in New England Journal of Medicine
titled The Relation between Blood Pressure and
Mortality Due to Coronary Heart Disease among
Men in Different Parts of the World
e. All of the above
47. True of False: Double-blind, randomized controlled
trials are associated with the least amount of bias.
a. True
b. False

34

SECTION I

PHARMACEUTICAL PRACTICE

48. True or False: A well-conducted study has


internal validity only.
a. True
b. False
49. The results of a randomized controlled trial that
compares insulin delivered via a pump with insulin
injected 3 times daily shows 18% reduction in HbA1C for
patients on the pump (95% confidence interval, 1%
22%). True or False: The result is statistically significant.
a. True
b. False
50. True or False: The confidence interval determines
whether the result is clinically significant.
a. True
b. False
51. Continuous data are used to describe which of the
following?
a. Blood sugar level
b. Blood pressure
c. Mortality
d. Gender
e. a and b only
52. The combination of key words that will return the
highest number of results is:
a. Propranolol AND hypertension
b. Propranolol NOT hypertension
c. Propranolol OR hypertension
d. Propranolol WITH hypertension
e. Propranolol WITHOUT hypertension
53. To find out if daptomycin and ceftazidime can be
safely administered through a Y-site, it would be best
to consult:
a. Cecil Textbook of Medicine
b. Drugs in Pregnancy and Lactation (Briggs)
c. King Guide to Parenteral Admixtures
d. Merck Index
e. Stockleys Drug Interactions
54. Yahoo.com is an example of a:
a. Search directory
b. Search engine
c. Web site
d. Web dictionary
e. None of the above
55. The Weber Effect states:
I. Adverse drug reactions always follow a normal
distribution
II. Healthcare professionals must report adverse
drug reactions in an online database
III. Reporting of adverse drug reactions increases until
the middle to end of the second year of marketing
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

56. A well-conducted study will have:


a. internal validity but no external validity.
b. both internal and external validity.
c. external validity but no internal validity.
d. no internal and external validity.
57. Phase IV clinical studies are commonly known as?
a. Pharmacokinetic study
b. Preclinical study
c. Post-Marketing Surveillance study
d. Prevention study
e. Quality of life study
58. In clinical research, beta refers to which of the
following:
a. the null hypothesis being true
b. the probability of making a type II error
c. degree to which conclusions about causes of
relations are likely to be true
d. cause-effect relationships
e. None of the above
59. Statistical power of a study is:
a. used to determine sample size.
b. determined after enrollment.
c. determined before enrollment.
d. a and c only.
e. All of the above.
60. A medication use evaluation is:
I. An evaluative method; reviewing practitioner
prescribing, pharmacist dispensing, and patient
use of medications is considered
II. An ongoing, systematic process designed to
maintain the appropriate and effective use of the
drug
III. Designed to improve quality of care for patients
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

61. What is nominal data?


a. Categorical data in which the order of the
categories is arbitrary
b. A type of data in which order is important
c. A type of measurement data
d. All of the above
62. Which of the following are ethical considerations
when conducting a study?
a. Institutional Review Board approval
b. Informed consent
c. Power of Study
d. Confidentialitiy
e. All of the above
63. Which of the following would be best describing this
example: a prescription for Protonix is being switched
to Prevacid due to formulary protocol in a hospital
pharmacy.

CHAPTER 4

a.
b.
c.
d.

Therapeutic interchange
Generic substitution
Pharmaceutical equivalence
Pharmaceutical alternative

64. The role of a pharmacist in evidence-based medicine


includes which of the following:
I. Accurately integrating medical literature
II. Evaluating levels of evidence from clinical studies
III. Comprehensively reviewing literature
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

65. A regularly updated list of medication used in the


diagnosis, prophylaxis, or treatment of disease is
called a:
a. Compendium
b. Policy
c. Formulary
d. Medication Account
e. Guideline
66. An analysis of all patients randomized in a study,
even if they fail to comply or drop out is called?
a. Regression analysis
b. Intention to treat analysis
c. Per-protocol analysis
d. Epidemiologic surveillance
e. None of the above
67. Oversight of policies and procedures related to all
aspects of medication use within an institution are
the responsibility of which committee?
a. Institutional Review Board
b. Pharmacy and Therapeutics Committee
c. Safety group
d. Quality Assurance Committee
e. Drug Formulary Committee
68. Additions to the formulary with restrictions in place
for improved therapeutic outcomes are considered:
a. Guided-use strategies
b. Drug use evaluations
c. Orphan drugs
d. Non-label use
e. None of the above
69. Which of the following principles should guide the
off-label use of medications?
a. Patient safety
b. Pharmacy and Therapeutics Comittee protocol
for use
c. Comprehensive and balanced review of the
evidence
d. All of the above
70. If a pharmacist evaluates a patients planned drug
therapy before dispensing the medication, this is
considered a:

a.
b.
c.
d.
e.

Drug Information Resources

35

Concomitant medication use evaluation


Prospective medication use evaluation
Retrospective medication use evaluation
Prevention medication use evaluation
None of the above

71. A patient who just started taking atenolol presents to


a pharmacy with a blood pressure of 132/78 and pulse
of 54 beats per minute. What is the most appropriate
action?
a. Advising the patient that these are normal values
and not to worry
b. Calling the physician and suggesting that
metoprolol might have a less-pronounced effect
on the patients heart rate
c. Asking the patient if he has noted any dizziness
on standing or decreased exercise tolerance
d. Advising the patient to discontinue atenolol
immediately
72. When counselling a patient on the use of Nexium,
which of the following is most appropriate for the
pharmacist to make?
a. Take this medication once a day before breakfast.
b. This medication may cause sedation.
c. This medication is used to treat your toenail
infection.
d. This medication is used to treat your high blood
pressure condition.
73. The purpose(s) of a meta-analysis include:
I. Decrease the chance of a type I error
II. Increase sample size
III. Decrease the likelihood of beta error
a.
b.
c.
d.
e.

I only
II only
I and III
II and III
I, II, and III

74. The most common instrument used in a meta-analysis


to assess data hetero-geneity is the:
a. Paired t-test
b. Chi square
c. Cochrans Q
d. Pearsons correlation
e. None of the above
75. Which of the following is an example of nominal data?
a. Gender
b. Blood glucose
c. Likert scales
d. Visual analog scales
e. All of the above
76. Which of the following are TRUE regarding a Phase I
study for a new hypoglycemic agent?
I. It includes patients for which the drug is
intended.
II. Over 1,000 patients are usually included in the
study.
III. It includes only healthy volunteers.

36

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

I only
III only
I and II
II and III
I, II, and III

77. Which of the following databases is available free of


charge to the public?
a. IPA
b. EMBASE
c. MEDLINE
d. Current Contents
78. A cohort study enrolled 800 cancer-free women
receiving hormone replacement therapy (HRT) and
800 matched controls. By the end of the study,
75 of the cohort had developed breast cancer and 38
of the controls had developed breast cancer. Given
these data, what is the relative risk of developing
breast cancer associated with exposure to HRT?
a. 0.507
b. 1.97
c. 1.05
d. 0.95
79. What source is used to find information on drug
compatibility and stability?
a. Remingtons Pharmaceutical Sciences
b. Trissels Handbook of Injectable Drugs
c. Martindale: The Complete Drug Reference
d. Drugs in Pregnancy and Lactation (Briggs)
e. Merck Index
80. Which of the following references provides Drug
information for the Health Care Professional?
a. USP DI Vol I
b. USP DI Vol II
c. USP DI Vol III
d. USP NF
e. None of the above
81. A woman informs a pharmacist that she is 36 weeks
pregnant. The pharmacist recommends that she
avoid ibuprofen. What reference provides the best
support for this recommendations?
a. Drugs in Pregnancy and Lactation (Briggs)
b. Merck Index
c. Physicians Desk Reference (PDR)
d. Trissels Handbook of Injectable Drugs
e. None of the above
82. Which of the following is not considered tertiary
literature?
a. AHFS Drug Information
b. International Pharmaceutical Abstracts (IPA)
c. Micromedex
d. Physicians Desk Reference (PDR)
e. None of the above

83. What source should be used to obtain information on


pharmaceutical compounding?
a. AHFS
b. Hansten and Horns
c. Martindale: The Complete Drug Reference
d. Remingtons Pharmaceutical Sciences
e. Trissels Handbook of Injectable Drugs
84. What source should be used for information on
foreign drugs?
a. Harrisons
b. Drugs in Pregnancy and Lactation (Briggs)
c. Martindale: The Complete Drug Reference
d. Remingtons Pharmaceutical Sciences
e. Trissels Handbook of Injectable Drugs
85. What source should be used to determine if there
is an interaction between citalopram and
clindamycin?
a. Hansten and Horn Drug Interaction Analysis and
Management
b. Index Nominum
c. Drugs in Pregnancy and Lactation (Briggs)
d. Remingtons Pharmaceutical Sciences
e. None of the above
86. What source does NOT contain information regarding
foreign drugs?
a. Index Nominum
b. Red Book Drug Topics
c. Micromedex
87. Which of the following resources provides a package
insert of atorvastatin calcium (Lipitor)?
a. AHFS Drug Information
b. Drug Facts and Comparisons
c. Physicians Desk Reference (PDR)
d. Red Book Drug Topics
e. All of the above
88. What is the name of the program developed by the
USP to report and evaluate medication errors?
a. MEDMARX
b. MedWatch
c. VAERS
d. None of the above
e. a, b, and c
89. Which of the following is NOT an example of how to
randomize patients in a study?
a. Blocked
b. Cluster
c. Stratified
d. Multi-center
e. None of the above

..................................................

Dispensing

CHAPTER

....................................................................................................................................................................

I.

Definitions and Purpose


A. Dispensing is the physical act of giving, providing,
or delivering a drug, chemical, device, or
medication for later oral ingestion, insertion,
application, injection, or other use.
B. The goal of dispensing is to select and dispense
medications in a manner that promotes safe and
effective use.
1. Use the National Drug Code (NDC) number and
other attributes to identify the correct drug
product.
a. The key identifier when selecting a product
in the U.S. is the NDC number, which is
unique to every drug product.
b. NDC is an 11-digit, three-segment number.
The format for all medications follows
55555-4444-22. The first segment of five
numbers is a labeler code assigned by the
Food and Drug Administration (FDA). A
labeler is any firm that manufactures,
repackages, or distributes a drug product.
The second segment of four numbers is the
product code, which indicates a specific
strength, dosage form, and formulation for a
particular product. Lastly, the third segment
of two numbers identifies the package size.
c. When filling a prescription, one can use an
NDC number to verify one has the correct
drug. Generics for the same medication each
have their own NDC.
d. When filling a prescription, verify the
product against its image (if available) and
confirm that it is in good condition. Confirm
the expiration date, dosage form, and
imprint code.
2. Use barcode technology: Newer systems can
include barcode technology that can scan for
the appropriate product and even prevent
dispensing unless the correct product is
selected. This practice is used in hospitals and
retail settings.
3. Check for expiration dates.
4. Check for drug interactions. When checking for
interactions, a pharmacist must review the
patients medication, evaluate and consider the
indication, consider the patients age and hepatic/
renal function, and whether or not the patient is
pregnant. These factors may alter drug therapy.

a. There are many types of drug interactions:


1) Drug-drug interactions
2) Drug-food interactions
3) Drug-disease interactions
4) Drug-herb interactions
5) Drug-pregnancy/lactation effects
b. Many pharmacy computer systems will have
a drug-interaction screening software
program in place. The integrated applications
are usually provided through vendors such as
First DataBank. As each prescription is filled,
the system automatically checks the
medication against other medications the
patient is taking. However, this system is not
always accurate because some people get
prescriptions filled at multiple pharmacies
and the computers are not on the same
network. Ask patients about their use of all
prescriptions, over-the-counter (OTC)
medications, herbal remedies, vitamins,
minerals, and other supplements. Determine
if the patient has any known allergies.
c. There are other resources available to check
for drug interactions including Clinical
Pharmacology, Facts and Comparisons,
Micromedex, and many others.
d. Herb-drug interactions are a concern due to
uncertainty as to how herbs and supplements
will interfere with other medication.
Resources and data are limited in this area.
1) An example of an herb-drug interaction is
St. Johns wort and cyclosporine. The
mechanism for this interaction is proposed
to be induction of cytochrome P-450
enzymes by St. Johns wort.
2) It is important to counsel patients on the
possibility of food-drug interactions.
Grapefruit or grapefruit juice has the
potential to alter the effects of various
medications, including antiarrhythmic
agents, immunosuppressive agents,
statins, and calcium channel blockers.
The interaction is likely the result of
inhibition of intestinal or liver metabolism
by cytochrome P-450.
e. The pharmacist should notify the prescriber
of serious drug interactions (those where the
patient risk exceeds any benefit from the

37

38

SECTION I

PHARMACEUTICAL PRACTICE

drug combination) and discuss alternative


therapy.
5. Identify and verify drugs by their generic,
brand, and/or common names. Most drugs have
several names: a chemical name, a generic name,
and a brand name. For example: [R-(R*, R*)]-2-(4fluorophenyl)-, d-dihydroxy-5-(1-methylethyl)-3phenyl-4-[(phenylamino) carbonyl]-1H-pyrrole-1heptanoic acid, calcium salt (2:1) trihydrate is the
chemical name for atorvastatin calcium, the
generic name for Lipitor.
a. Generic products contain the same active
ingredient but are not likely to contain the
same excipients (inactive ingredients). Generic
drugs may differ in shape, scoring,
configuration, release mechanisms, packaging,
colors, flavors, and preservatives from the
brand name product. The generic version
delivers the same amount of its active
ingredient and must have the same dosage
form, safety, strength, route of administration,
and conditions of use as the innovator/brand
name product. Generic drugs are subject to the
same FDA standards as all drugs and must be
manufactured under the same strict standards
of the FDAs good manufacturing practice
(GMP) regulations. Generic drugs must pass
stringent bioequivalency tests in humans to
ensure the generic version delivers the same
amount of active ingredient as the innovator/
brand equivalent.
b. Excipients, or inactive ingredients in drug
products, include fillers, binders, colors, and
coatings. An individual may be allergic or
sensitive to a specific excipient. Patients
should be asked about all of their allergies,
not just allergies to medications.
c. Therapeutic interchange is the process of
dispensing prescribed medications that are
chemically different but are therapeutically
similar to the medication prescribed. Normally
there are approved written guidelines or
protocols in a formulary system.
1) Therapeutic interchange is common in the
hospital setting. For example, a doctor may
prescribe esomeprazole (Nexium) 40 mg,
but the hospital pharmacy substitutes the
preferred drug, pantoprazole (Protonix).
However, this practice varies from
institution to institution and state to state.
Some states do not allow any therapeutic
interchange unless the prescriber is
contacted. Other states do not address the
issue at all.
d. Generic interchange is the process of
dispensing a medication produced by another
manufacturer that is the exact same chemical
entity as the brand name prescribed.
1) This practice also varies from state to
state. Some use positive formularies,
meaning that generics may be dispensed if
the drug appears on the formulary. Other
states use negative formularies that

prohibit generic interchange of selected


drugs. Using generic medications saves
money because the price can be 30% to
80% less than the brand name.
2) Consult the FDAs Approved Drug Products
with Therapeutic Equivalence Evaluations
(the Orange Book) for bioequivalence
when determining appropriate generic
products to dispense in lieu of a brand
name/innovator product.
6. Determine whether a particular drug dosage
strength or dosage form is commercially
available and whether it is available on a
nonprescription basis.
a. Some medications are available as a
prescription and an OTC product. Ibuprofen
200 mg (Motrin, Advil) is available OTC;
ibuprofen 400 mg, 600 mg, and 800 mg are
available by prescription. Other medications
have become OTC products after previously
being a prescription-only product. Cetirizine
(Zyrtec), loratadine (Claritin), and
omeprazole (Prilosec) are a few of the
medications that have made the switch from
prescription to OTC.
b. Often there are different routes of
administration are available for a therapeutic
agent. The route of administration is
determined by the therapeutic objective and
the properties of the drug used. Each route has
advantages and disadvantages, and the
administration should be suited to the patients
needs. The two most common routes of
administration are enteral and parenteral.
1) Enteral: Oral is the most common route of
administration. It is the easiest, most
convenient, and least expensive. There are
some disadvantages to the oral route:
slower onset of absorption and action;
variation in rate and degree of absorption
with gastrointestinal contents and motility;
cannot be used with nausea and vomiting;
cannot be used with patients who are
unconscious, have difficulty swallowing, or
can take nothing by mouth (NPO). The
patients ability and willingness to swallow
a solid dosage form is also a factor.
a) Sublingual, or under the tongue,
administration allows the drug to
enter the systemic circulation directly
and bypass the liver.
2) Rectal: Rectal administration may be used
in patients who have difficulty swallowing
or have nausea. In this form, the drug is not
inactivated by intestinal enzymes if the
drug is placed properly in the rectum.
3) Parenteral: Some examples of the parenteral
route are intravenous, subcutaneous, and
intramuscular. Some drugs must be given
by this route to stay in their active form.
Insulin glargine (Lantus) can only be given
as an injection because oral administration
would break down the medication before

CHAPTER 5

absorption could occur. Bioavailability of


drugs administered parenterally is usually
more rapid, extensive, and predictable.
Another advantage is that a parenteral
route can be used during emergency
therapy when a patient is unable to take
medications by mouth.
a) Intravenous is a common parenteral
route. Drug absorption is not dependent
on the GI tract and the effects are rapid.
However, rapid administration may
cause hemolysis and other adverse
effects.
b) Intramuscular injections permit the
administration of more irritating drugs
and larger volumes of solutions that
cannot be tolerated by other routes.
c) Subcutaneous (SC or SQ): SC injections
are given under the skin and provide a
rapid onset of action.
d) Transdermal administrations are
applied to the surface of a body part.
4) Inhalation: Inhaled drugs are those that
are administered through mucous
membranes of the respiratory tract by
nebulizer, face mask, pumps, or breathing
machine. Examples of inhaled drugs
include bronchodilators, corticosteroids,
and mucolytic agents.
E. Identify commercially available drug products by
their characteristic physical attributes.
1. Imprint codes
a. Imprint codes are used for quick
identification of solid dosage forms in drug
overdose cases, to identify unknown drug
products, and to allow patients to check that
they have been dispensed the correct
medication. Until 1995, there were no
regulations regarding imprint data on soliddosage forms of medications. Drugs exempt
from federal regulations are in Table 5-1.2
b. The FDA only requires drug firms to provide
their imprint information, along with their
listing forms, to the agencys Drug Listing
Table 5-1

Exemptions to Imprint Code Regulations

Drug products used in


When physical
clinical investigations
characteristics of the
Drug products intended
drug make it impossible
for use in
to imprint
bioequivalence
When the medication is
studies
dispensed in a controlled
Prescribed drug products
health care setting (i.e.,
compounded
doctors office)
extemporaneously by When the drug is not
pharmacists
dispensed to patients
Drugs classified as
for self administration.
radiopharmaceutical
drug products

Dispensing

39

Team, where it is entered into a database.


The data captured include identifiers such as
shape, size, color, imprint code, scoring, and
coating. The database also incorporates
imprint graphics, which describe a logo that
does not consist of conventional characters.
c. For example, tadalafil 10 mg (Cialis) is a
teardrop shaped, yellow tablet imprinted with C
10; tadalafil 20 mg (Cialis) is a teardrop
shaped, yellow tablet imprinted with C 20.
d. The Division of Drug Information can identify
oral-dosage drugs based on physical
appearance and markings. This service offered
by the FDA is free to the American public.
Drug-identification inquiries can be sent to
the Division of Drug Information via telephone
at 888-INFOFDA (888-463-6332), via fax (301-8274577), or via e-mail (druginfo@cder.fda.gov).
e. Dietary supplements are not required to
have imprint information.
2. Packaging and labeling
a. For some medications, the original package is
important to the proper storage of the
medication, or to reference manufacturer
labeling. For example, nitroglycerin sublingual
tablets must be stored in their original, tightly
closed, glass bottle because potency can be lost
by adsorption if repackaged. Packaging can
vary between different strengths or types of
medications.
3. OTC medications: The drug facts label format
was based on the nutrition facts food label. It
uses an easy to read format and includes:
a. The products active ingredients, including
the amount in each dosage unit.
b. The purpose of the medication.
c. The uses and indications for the drug.
d. Specific warnings, including when the
product should not be used, and when it is
appropriate to consult a doctor or
pharmacist. The warnings section also
describes side effects that could occur and
substances or activities to avoid.
e. Dosage instructions addressing when, how,
and how often to take the medication.
f. The products inactive ingredients, which is
important for those with specific allergies.
4. Dietary supplements:
a. The FDA regulates dietary supplements
(defined by the FDA as being composed only
of essential nutrients, such as vitamins,
minerals, proteins, herbs, or similar
nutritional sources) differently than food or
OTC/prescription drug products. Dietary
supplement manufacturers do not have to get
FDA approval or register their products
before producing or selling them. The Dietary
Supplement Health and Education Act of 1994
(DSHEA) states that the dietary supplement
manufacturer is responsible for ensuring that
the supplement is safe before it is marketed.
The FDA is responsible for monitoring safety
via adverse event reporting and product

40

SECTION I

PHARMACEUTICAL PRACTICE

information. The manufacturers must ensure


that the label is truthful and not misleading.
Good Manufacturing Processes (GMP),
determined by the FDA, must be in place.
These govern the preparation, packing, and
holding of dietary supplements under
conditions that ensure their safety.
The manufacturer, however, does not have to
prove supplement quality.4
b. There are third-party testing organizations
that certify dietary supplements, which
include USP, NSF International, and
Consumer Lab. Certifications are important
because many herbs and supplements have
no identifying features on the pill or capsule.
Keeping the consumer well informed about
herbs and supplements is an important role
for a pharmacist.
1) USP is an independent,
nongovernmental, nonprofit public
health organization that verifies the
identity, strength, purity, and quality of
dietary supplements. Products that pass
USP scrutiny receive a USP Verified
mark on the label (Figure 5-1).
2) NSF International verifies products for
content and label accuracy, purity,
contaminants, and good manufacturing
processes.
3) Consumer Lab tests various products
against various claims in a qualitative
manner (Figure 5-2).

Figure 5-1USP Verified Dietary Supplement mark.

(Courtesy

www.uspverified.org).

This seal
is a registered
certification mark

Product met
CLs standards

Product was tested


for ingredient quality

CL is independent
and consumerfocused

This specific
ingredient was
tested

Product was
laboratory-tested
by experts

Figure 5-2Consumer Lab Qualitative Testing.


LLC).

You can learn


more about this
product, ingredient,
and testing at our
web site

(ConsumerLab.com,

F. Interpret and apply pharmacokinetic parameters


and quality assurance data to determine
bioequivalence among manufactured drug
products and identify products for which
documented evidence of inequivalence exists.
1. Drug products are considered pharmaceutical
equivalents if they contain the same active
ingredient, are of the same dosage form and
route of administration, and are identical in
strength or concentration.
2. Generic drugs must pass stringent
pharmacokinetic and bioequivalency tests in
humans to be noted as bioequivalent to the
innovator/brand product. The tests ensure the
generic version delivers the same amount of
active ingredient as the innovator/brand
equivalent.
3. The Orange Book is published by the FDA and
aides in determining bioequivalence between
drug products made by different
manufacturers.3 The Orange Book uses a twoletter coding system to help determine which
drug products are therapeutically equivalent.
a. Codes that begin with A are considered to be
therapeutically equivalent to other
pharmaceutically equivalent products.
1) Drugs that have no known equivalence or
suspected bioequivalence problems are
designated AA, AN, AO, AP, or AT,
depending on the dosage form.
2) The Orange Book has a list with
therapeutic equivalence (TE) evaluations
for FDA-approved drug products. TE
codes are composed of 2 letters (e.g., AB,
AB2, BX). The first letter indicates
whether the approved product is
therapeutically equivalent to the
reference-listed drug (RLD). If it is, then
the drug will be designated with the letter
"A." Drug products with a TE code
starting with "B" are not considered to be
therapeutically equivalent, or there is a
problem in bioequivalence. The second
letter provides additional information on
the basis of the FDAs evaluations, such
as route of administration or formulation.
b. Drug products with codes that begin with B
are not considered therapeutically
equivalent to other pharmaceutically
equivalent products. Drugs fall under this
category for one of three reasons: 1) the drug
has documented bioequivalence problems or
significant potential for problems, 2) quality
standards are inadequate or the FDA has
insufficient basis to determine therapeutic
equivalence, or 3) the drug products are
under regulatory review. B* indicates that
the drug previously received an A or B code,
but new information has been received by
the FDA that raises questions regarding
therapeutic equivalence, and the FDA will
not take a position on the drug until it
completes an investigation and review.

CHAPTER 5

G. Identify and communicate appropriate information


regarding packaging, storage, handling,
administration, and disposal of medications.
a. Packaging
1. The Poison Prevention Act of 1970 states
that child resistant closures must be on
prescription containers unless the
prescription is for an exempted drug or if
the patient has authorized easy-open
packaging.
2. Examples of exemptions from this rule are
sublingual dosage forms of nitroglycerin,
potassium supplements in unit dose forms,
and oral contraceptives in mnemonic
packaging.
b. Storage
1. Expiration date: The expiration date of a
medication as determined by USP states that
the expiration date must be no later than the
expiration date on the manufacturers
container or one year from the date the drug
is dispensed, whichever date is earlier. The
expiration date for certain products such as
insulin is different. For example, the
expiration date on insulin products is
24 months from the date of manufacture.
However, the stability of the insulin is
altered once the product is opened and it
therefore bears a new expiration date.
The expiration information can be found
in the products package insert. For example,
insulin glargine (Lantus) and other
insulin vials should discarded 28 days after
the product is opened. Other drug
products may also have new expiration
dates when opened. For example,
Latanoprost (Xalatan) needs to be stored
in the refrigerator until first use, then
may be stored at room temperature for
6 weeks.
c. Handling
1. Certain medications need careful handling to
prevent degradation of the product.
2. The pharmacist should take precaution
when preparing medications for patients.
An example of this would be not shaking a
vial of colistimethate for reconstitution, but
rather gentle swirling.
3. Overall handling of sterile products is
briefly reviewed in Chapter 3 on
compounding.
d. Administration
1. When a medication is dispensed to the
patient, the prescription label must have
specific information*:
 Pharmacy name, address, and telephone
number
 Assigned prescription number

*Specific state laws may require additional information.

Dispensing

41

 Date of the prescription or the date of its

filling or refilling (state law often


determines which date is to be used)
 Name of patient
 Name of prescriber
 Directions for use and any cautionary
statements
 Controlled substance schedules II, III, or IV
must contain the following warning:
CAUTION: Federal law prohibits the
transfer of this drug to any person other
than the patient for whom it was
prescribed.
2. Most medications are to be discarded in
the trash, not flushed down the toilet.
This should be done by taking the
medications out of their original container
and mixing with an undesirable substance
such as coffee grounds or cat litter.
However, the Office of National Drug
Control Policy states that certain
medications (e.g., fentanyl) can be disposed
of in the toilet.
3. Patients should be aware of safe and legal
disposal of drug devices. (e.g., needles
disposed in appropriate sharps containers).
4. Disposal instruction is not limited to patient
knowledge but this knowledge is also
important for the pharmacist, who may have
to dispose of hazardous materials such as
chemotherapeutic drugs.
H. Identify and describe the use of equipment and
apparatus required to administer medications.
a. The pharmacist should be able to describe in
patient-appropriate language, how each
medication should be used. This is particularly
important for describing proper use of inhalers,
nebulizers, insulin administration, auto
injectors (e.g., EpiPen), and ophthalmic and
otic preparations.
b. In addition to education regarding how to use a
device, the pharmacist should be able to
describe other elements of medication use
(described in greater detail in Chapter 6, Patient
Education).
1. Possible adverse effects and their
management
2. Therapeutic drug monitoring including
needed laboratory tests
3. What to do in the event of a missed dose
4. Helpful nondrug activities

References
Kiliany BJ, Kremzner M, Nelson T: The evolution of
imprint identification, Pharm Times. Available at http://
www.pharmacytimes.com/issue/pharmacy/2006/200603/2006-03-5374. Accessed June 2009.
FDA: Electronic orange book. Available at http://www.fda.
gov/cder/ob/default.htm. Accessed September 2008.
FDA: Dietary Supplement Health and Education Act of 1994.
Available at http://www.cfsan.fda.gov/dms/dietsupp.
html. Accessed September 2008.

42

SECTION I

PHARMACEUTICAL PRACTICE

REVIEW QUESTIONS
(Answers and Rationales on page 324.)
1. The mechanism of action of Maxair is closely
related to which of the following agents?
a. Zafirlukast
b. Albuterol
c. Ipratropium
d. Nedocromil
e. None of the above
2. Which of the following is/are available dosage
strength(s) of oral Norvasc?
I. 2.5 mg
II. 10 mg
III. 25 mg
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II and III

3. Which of the following auxiliary labels should be


affixed to the container for Xalatan?
a. May discolor urine
b. Refrigerate before opened
c. Do not freeze
d. b and c only
4. A consulting pharmacist in a nursing home is asked by
a nurse for advice regarding selegiline and sertraline
administration for an 85-year-old patient. The patient
has received the following new orders:
Sertraline 25 mg PO q AM
Selegiline 5 mg PO at breakfast and lunch
What is the most appropriate recommendation?
a. Administer the sertraline at bedtime.
b. Separate the morning medication
administration by at least 2 hours.
c. Call the physician to warn of a potential drug
interaction.
d. Call the physician to recommend a higher dose
of sertraline.
5. A 62-year-old patient is transferred from a skilled
nursing facility to the emergency department after a
fall. The emergency department doctor writes an
order for IV meperidine 15 mg/h. During medication
reconciliation, the pharmacist notices that the
patient has been taking 10 mg selegiline q AM.
What is the most appropriate action?
a. Ensure timely delivery of the meperidine to the
patient.
b. Recommend changing to oral meperidine.
c. Recommend an alternative medication for pain
management because of a potential drug
interaction.
d. Recommend an alternative medication for pain
management because of the patients age.
6. A patient brings in a vial of cloudy NPH insulin.
Examination of the medication profile reveals

simultaneous use of NPH and regular insulin.


Which of the following is the MOST PROBABLE
explanation for the cloudy appearance of the
NPH insulin?
a. The insulin has been improperly stored.
b. The insulin has expired.
c. The insulin has been contaminated.
d. The insulin is expected to be cloudy.
7. What is the generic name of Invirase?
a. Ritonavir
b. Saquinavir
c. Nelfinavir
d. Indinavir
8. A patient has a prescription for Lansoprazole,
which is not on the formulary of his insurance. The
pharmacist calls the prescriber to recommend a
change to a similar medication that is on the
formulary. Which of the following would be the most
appropriate recommendation?
a. Latanoprost
b. Fluconazole
c. Pantoprazole
d. Aripiprazole
9. An uninsured patient has a prescription for Lipitor
10 mg daily. After discussing the cost of the
prescription with the patient, the pharmacist calls the
prescriber to recommend a change to a similar
medication that is less expensive. Which of the
following would be the most appropriate
recommendation?
a. Simvastatin 10 mg daily
b. Simvastatin 20 mg daily
c. Crestor 5 mg daily
d. Crestor 10 mg daily
10. What is the generic name of Aciphex?
a. Aripiprazole
b. Rabeprazole
c. Pantoprazole
d. Albentazole
11. What is the generic name of Noxafil?
a. Posaconazole
b. Methimazole
c. Voriconazole
d. Albentazole
12. What is the generic name of Terazol?
a. Tramadol
b. Tioconazole
c. Terconazole
d. Miconazole
13. A patient who has been seizure free on phenytoin
suspension 3.5 mL PO twice a day is now receiving
feedings and medication through a nasogastric
tube. What would be the most appropriate
recommendation to ensure that the patients
phenytoin level stays at a therapeutic level?

CHAPTER 5

a.
b.
c.
d.

Recommend enteral feeding that contains less


protein and more fat.
Hold tube feedings for 1 hour before and after
phenytoin administration.
Obtain daily phenytoin serum levels and adjust
the dose accordingly.
Ensure that the phenytoin is diluted with
distilled water before instillation.

14. Which of the following brand(s) can be used for the


treatment of pruritus that is associated with partial
biliary obstruction?
I. Prevalite
II. Questran
III. Megace
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

15. Which of the following may produce significant


hypotension with the initial dose?
a. Reserpine
b. Prazosin
c. Clonidine
d. Propanolol
e. Methyldopa
16. What is the rationale for prescribing benztropine
with a phenothiazine?
a. Benztropine reduces extrapyramidal side
effects.
b. Benztropine enhances absorption.
c. Benztropine decreases the required
phenothiazine dose.
d. Benztropine prevents gastric irritation.
e. Benztropine is an antidepressant.
17. Which of the following is most dangerous when
infecting the orbit?
a. Pseudomonas aeruginosa
b. Streptococcus thermophilus
c. Bacillus subtilis
d. Aspergillus niger
e. Escherichia coli
18. Which of the following is used to selectively increase
neutrophil production?
a. Thrombopoietin
b. Filgrastim
c. Erythropoietin
d. Interleukin 11
e. Sagramostim
19. Which of the following may be used in the treatment
of a 5-year-old child with diarrhea?
a. Intravenous saline
b. Antibiotics
c. Oral rehydration
d. All of the above
e. None of the above

Dispensing

43

20. Which of the following may occur with bulimia?


a. Hypernatremia, hypokalemia, and
hypochloremia
b. Hyponatremia, hypokalemia, and
hypochloremia
c. Hyponatremia, hyperkalemia, and
hyperchloremia
d. a and b
c. a and c
21. Adderall is a:
a. stimulant
b. narcotic
c. depressant
d. antidepresant
e. diuretic
22. It is recommended that patients take prazosin just
before bedtime to minimize which side effect?
a. Insomnia
b. Rash
c. Dizziness
d. Urinary frequency
e. Palpitations
23. Which of the following products may be directly
substituted for Claritin?
a. Sudafed
b. Bonine
c. Allegra
d. Alavert
e. Contact
24. Which of the following is NOT an indication for
nitroglycerin?
a. Angina
b. Chronic hypertension
c. Perioperative hypertensive emergency
d. Pulmonary hypertension
e. Congestive heart failure
25. Sulfonylureas:
a. may cause an adverse reaction when consumed
with alcohol.
b. stimulate insulin release from the pancreas.
c. carry a risk of hypoglycemia.
d. a and b
e. a, b, and c
26. Simethicone is most likely included in which of the
following OTC products?
a. Stool softener
b. Cough suppressant
c. Decongestant
d. Antacid
e. None of the above
27. What are the available dosage strength(s) of oral
Lexapro?
I. 5 mg
II. 20 mg
III. 40 mg

44

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

I only
III only
I and II
II and III
I, II, and III

a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

28. Metformin:
a. may cause lactic acidosis.
b. is safe to use in patients with renal failure.
c. shows maximum effect after the first dose.
d. is excreted predominantly in the feces.
e. works by stimulating insulin release.

37. Furosemide is a(n):


a. angiotensin-receptor blocker.
b. angiotensin-converting enzyme inhibitor.
c. beta blocker.
d. thiazide diuretic.
e. loop diuretic.

29. Acarbose:
a. is an alpha-glucosidase inhibitor
b. is safe to use in patients with chronic intestinal
disease.
c. is less than 2% absorbed.
d. a and b
e. a and c

38. How many tablets of Darvocet-N 100 is in the


maximum adult daily dose?
a. 6 tablets
b. 8 tablets
c. 10 tablets
d. 12 tablets
e. 14 tablets

30. Glyburide:
a. may cause a disulfiram-like reaction.
b. has an onset of action of 1560 minutes.
c. can be used to treat type 1 diabetes mellitus.
d. a and b
e. a, b, and c

39. Metoprolol is a(n):


a. angiotensin-receptor blocker.
b. angiotensin-converting enzyme inhibitor.
c. beta blocker.
d. thiazide diuretic.
e. loop diuretic.

31. Ranitidine:
a. is a histamine-2 antagonist.
b. can be used to treat peptic ulcer disease.
c. may cause dizziness.
d. is excreted in both the urine and feces.
e. All of the above

40. Hydrochlorothiazide is a(n):


a. angiotensin-receptor blocker.
b. angiotensin-converting enzyme inhibitor.
c. beta blocker.
d. thiazide diuretic.
e. loop diuretic.

32. True or False: Metformin can be used to treat type 1


diabetes mellitus.
a. True
b. False

41. Candesartan is a(n):


a. angiotensin-receptor blocker.
b. angiotensin-converting enzyme inhibitor.
c. beta blocker.
d. thiazide diuretic.
e. loop diuretic.

33. True or False: H pylori can cause peptic ulcer disease.


a. True
b. False
34. What is the DEA schedule for Ultram?
a. C-I
b. C-II
c. C-III
d. C-IV
e. None of the above
35. Captopril is a(n):
a. angiotensin-receptor blocker.
b. angiotensin-converting enzyme inhibitor.
c. beta blocker.
d. thiazide diuretic.
e. loop diuretic.
36. Which of the following products is/are not appropriate
for a patient taking warfarin (Coumadin)?
I. Percodan
II. Demerol
III. Dilaudid

42. Tamoxifen is a(n):


a. rapid-acting insulin.
b. HMG-CoA reductase inhibitor.
c. antiestrogen.
d. corticosteroid.
e. sulfonylurea.
43. Glipizide is a(n):
a. rapid-acting insulin.
b. HMG-CoA reductase inhibitor.
c. antiestrogen.
d. corticosteroid.
e. sulfonylurea.
44. Simavastatin is a(n):
a. rapid-acting insulin.
b. HMG-CoA reductase inhibitor.
c. antiestrogen.
d. corticosteroid.
e. sulfonylurea.

CHAPTER 5

45. Methylprednisolone is a(n):


a. rapid-acting insulin.
b. HMG-CoA reductase inhibitor.
c. antiestrogen.
d. corticosteroid.
e. sulfonylurea.
46. Lispro is a(n):
a. rapid-acting insulin.
b. HMG-CoA reductase inhibitor.
c. antiestrogen.
d. corticosteroid.
e. sulfonylurea.
47. Nedocromil is a(n):
a. mast cell stabilizer.
b. b-agonist.
c. calcium-channel blocker.
d. H2 antagonist.
e. H1 antagonist.
48. Albuterol is a(n):
a. mast cell stabilizer.
b. b-agonist.
c. calcium-channel blocker.
d. H2 antagonist.
e. H1 antagonist.
49. Diphenydramine is a(n):
a. mast cell stabilizer.
b. b-agonist.
c. calcium-channel blocker.
d. H2 antagonist.
e. H1 antagonist.
50. Verapamil is a(n):
a. mast cell stabilizer.
b. b-agonist.
c. calcium-channel blocker.
d. H2 antagonist.
e. H1 antagonist.
51. Ranitidine is a(n):
a. mast cell stabilizer.
b. b-agonist.
c. calcium-channel blocker.
d. H2 antagonist.
e. H1 antagonist.
52. A patient has been taking prednisone for 5 days
following an exacerbation of asthma symptoms. He
begins treatment with cromolyn sodium. True or
False: He should immediately stop prednisone with
the first dose of cromolyn.
a. True
b. False
53. Flexeril is available in which of the following
strength(s)?
I. 2.5 mg
II. 5 mg
III. 10 mg

a.
b.
c.
d.
e.

Dispensing

I only
III only
I and II
II and III
I, II, and III

54. Fluticasone is a:
a. H1 antagonist.
b. H2 antagonist.
c. b-agonist.
d. corticosteroid.
d. b antagonist.
55. Which of the following is useful in the treatment
of acute, productive cough?
a. Guaifenesin
b. Montelukast
c. Ipratropium
d. a and b
e. a, b and c
56. Which of the following is first-line treatment for
intermittent asthma?
a. Cromolyn sodium
b. Albuterol
c. Prednisone
d. 100% oxygen
e. Ipatropium
57. Guaifenesin:
a. is an expectorant.
b. is a cough suppressant.
c. thins bronchial secretions.
d. a and c
e. b and c
58. Which of the following is an indication for
brimonidine?
a. Benign prostatic hypertrophy
b. Epilepsy
c. Glaucoma
d. Increased intracranial pressure
e. Metabolic alkalosis
59. Which of the following is the correct dose of
finasteride for benign prostatic hypertrophy?
a. 0.1 mg daily
b. 0.5 mg daily
c. 1 mg daily
d. 5 mg daily
e. 10 mg daily
60. Which of the following is the correct dosage
of naproxen?
a. 750 mg as initial dose for acute gout
b. 500 mg twice daily for acute migraine
c. 500 mg twice daily for rheumatoid arthritis
d. All of the above
e. None of the above
61. What is the most appropriate initial treatment
for status epilepticus?

45

46

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

Phenytoin
Diazepam
Ethosuximide
Glutethimide
Paraldehyde

62. Which of the following may cause a lupus-like


reaction?
a. Guanethidine
b. Methyldopa
c. Hydralazine
d. Diazoxide
e. Reserpine
63. All of the following are calcium channel blockers
EXCEPT?
a. Amlodipine
b. Ibutilide
c. Nifedipine
d. Verapamil
e. Diltiazem
64. A 70-year-old man with renal insufficiency is to be
treated with a tetracycline. Which of the following
will not accumulate to a great degree in this patients
blood?
a. Minocycline
b. Demeclocycline
c. Oxytetracycline
d. Tetracycline
e. Doxycycline
65. Which of the following may cause orthostatic
hypotension?
I. Prazosin
II. Sildenafil
III. Amitriptyline
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

66. Vyvanse is indicated for:


a. Insomnia
b. ADHD
c. Depression
d. Hyperlipidemia
e. Migraine headaches
67. How many milligrams of oxycodone HCl are in the
lowest strength of Percocet?
a. 1 mg
b. 2.5 mg
c. 5 mg
d. 7.5 mg
e. 10 mg
68. Cholestyramine interferes with the oral
absorption of:
a. phenobarbital.
b. chlorothiazide.

c.
d.
e.

warfarin.
a and b
a, b, and c

69. All of the following are brands of Amoxicillin EXCEPT:


a. Moxatag
b. Trimox
c. Kantrex
d. Amoxil
e. Wymox
70. Anticonvulsants interfere with the
metabolism of:
a. riboflavin
b. tyrosine
c. renin
d. folic acid
e. pyridoxine
71. Zyvox is available as:
I. IV injection
II. Tablets
III. Oral suspension
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

72. Which of the following species is most likely to


cause purulent boils on the skin?
a. Streptococcus
b. Staphylococcus
c. Candida
d. Aspergillus
e. Pseudomonas
73. Which of the following is the most appropriate
treatment for conjunctival herpes simplex virus
(HSV) infection?
a. Mupirocin
b. Idoxuridine
c. Bacitracin
d. Amphotericin B
e. Thiabendazole
74. Which of the following should NOT be used to treat
candidal infections?
a. Terconazole
b. Miconazole
c. Nystatin
d. Tolnaftate
e. Clotrimazole
75. Which of the following is an indication for
methotrexate?
a. Warts
b. Tinea infection
c. Psoriasis
d. Acne
e. Seborrhea

CHAPTER 5

Dispensing

47

76. Which of the following may occur with


corticosteroid ingestion?
a. Disseminated infection
b. Immunosuppression
c. Increased risk of infection
d. Masking of infectious symptoms
e. All of the above

84. Which of the following is NOT a common symptom


of antipsychotic medications?
a. Akathisia
b. Anhedonia
c. Diabetes
d. Weight gain
e. Tardive dyskinesia

77. Compared with other NSAIDs, which of the following


is a benefit associated with the use of piroxicam?
a. Once-daily dosing
b. No gastric side effects
c. Cytoprotective effects
d. Inexpensive
e. Different mechanism of action

85. A 65-year-old woman with congestive heart failure


and atrial fibrillation is diagnosed with glaucoma.
What is the most appropriate topical treatment?
a. Timolol
b. Timolol plus dorzolamide
c. Latanoprost
d. Epinephrine
e. Any of the above

78. Which of the following is an indication for


clomiphene citrate?
a. Dysmenorrhea
b. Nausea
c. Depression
d. Infertility
e. Psoriasis
79. Which of the following is detected by the e.p.t. home
pregnancy test?
a. Human chorionic gonadotropin
b. Prolactin
c. Progestin
d. Progesterone
e. Estradiol
80. Which of the following is/are the mechanism of
action of nitric oxide (NO)?
a. Increased smooth muscle activity
b. Stimulation of nucleotide c-GMP
c. Smooth muscle relaxation
d. a and b
e. b and c
81. Which of the following drug combinations are found
in Advair?
a. Flunisolide and salmeterol
b. Fluticasone and salmeterol
c. Beclomethasone and formoterol
d. Fluticasone and formoterol
e. None of the above
82. Which of the following is the preferred method
to evaluate the efficacy of warfarin therapy?
a. Prothrombin time (PT)
b. Partial Thromboplastin Time (PTT)
c. Bleeding time
d. International Normalized Ration (INR)
e. a, b, and d
83. InnoPran XL is available as:
a. 80 mg
b. 120 mg
c. 180 mg
d. a and b
e. b and c

86. What is the rationale for the preferred use of inhaled


corticosteroids over oral corticosteroids in the
treatment of asthma?
a. Increased efficacy
b. Decreased systemic side effects
c. Increased ease of use
d. a and b
e. b and c
87. Lisinopril is a:
a. b blocker.
b. a1 blocker.
c. angiotensin-recepter blocker.
d. angiotensin-converting enzyme inhibitor.
e. diuretic.
88. True or False: It takes 2 to 6 weeks after initiation of
cromolyn sodium to see therapeutic effects for the
maintenance treatment of asthma.
a. True
b. False
89. True or False: Angiotensin-converting enzyme (ACE)
inhibitors combined with angiotensin-receptor blocker
(ARB) provide greater efficacy then either alone.
a. True
b. False
90. True or False: Antihypertensive agents of different
classes may be combined in patients refractory to
single-drug treatment.
a. True
b. False
91. Bicitra is the U.S. brand name for:
a. Sodium citrate and citric acid
b. Dibasic sodium phosphate
c. Bismuth subsalicylate
d. Magaldrate and simethicone
e. Calcium carbonate
92. Aprepitant (Emend) is:
I. Available as capsules
II. A substance P antagonist
III. Used to prevent acute and delayed nausea and
vomiting associated with cancer chemotherapy

48

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

I only
III only
I and II only
II and III only
I, II, and III

93. Which of the following is the most appropriate initial


treatment for a patient with newly diagnosed type
2 diabetes?
a. Glyburide
b. Insulin
c. Metformin
d. Acarboze
e. Pioglitazone
94. Which of the following agent(s) is/are classified as a
sulfonylurea?
I. Chlorpropamide
II. Glipizide
III. Tolterodine
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

95. Type 1 diabetes mellitus:


a. may be due to autoimmune phenomena.
b. usually presents before puberty.
c. must be treated with insulin.
d. commonly presents with polyuria, polydypsia,
and polyphagia.
e. All of the above
96. Type 2 diabetes mellitus:
a. does not have a genetic component.
b. requires insulin therapy.
c. is most likely to occur in thin, malnourished
patients.
d. is a relative, not complete, lack of insulin.
e. All of the above
97. Diabetes mellitus can be diagnosed in which of the
following situations?
a. Fasting blood glucose greater than 126 mg/dL
b. Random plasma glucose greater than 200 mg/dL
c. Oral glucose challenge 2-hour plasma level
greater than 200 mg/dL
d. Any of the above
e. a or b
98. Which of the following is classified as an NSAID?
I. Celecoxib
II. Ketorolac
III. Acetaminophen
a.
b.
c.
d.
e.

I only
III only
I and II
II and IIII
I, II, and III

99. True or False: Insulin glargine is ultra fast acting.


a. True
b. False
100. What are the active ingredients in Prempro?
a. Conjugated estrogen and methyltestosterone
b. Conjugated estrogen and medroxyprogesterone
c. Ethinylestradiol and medroxyprogesterone
d. Drospirenone and ethinyl estradiol
e. None of the above
101. All of the following medications are protease
inhibitors EXCEPT:
a. Reyataz
b. Lexiva
c. Viramune
d. Agenerase
e. Viracept
102. Which of the following antiretroviral drugs are
available as syrup or oral solution?
a. Epivir
b. Ziagen
c. Videx
d. Norvir
e. All of the above
103. Which of the following is/are considered rapidacting insulin?
I. Apidra
II. Humalog
III. Novolog
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

104. All of the following drugs are prostaglandin analogs


EXCEPT:
a. Xalatan
b. Lumigan
c. Azopt
d. Travatan
e. Rescula
105. Which HMG-CoA reductase inhibitor is least likely to
have drug interactions?
a. Pravastatin
b. Lovastatin
c. Fluvastatin
d. Atorvastatin
e. Simvastatin
106. What is the brand name for levalbuterol?
a. Ventolin
b. Serevent
c. Xopenex
d. Flovent
e. None of the above

CHAPTER 5

Dispensing

107. What is the dose of trazodone for depression?


a. 10 mg per day
b. 25-50 mg per day
c. 1-2 grams per day
d. 150 mg per day
e. 5 grams per day

115. Latanoprost:
a. has an onset of action of 12 hours.
b. has a peak effect at 812 hours.
c. has a volume of distribution of 1 L/kg.
d. is excreted unchanged in the urine.
e. has a half-life of elimination of 60 minutes.

108. Axert is available as:


I. 6.25 mg
II. 12.5 mg
III. 30 mg

116. Moduretic contains:


a. atenolol and chlorthalidone.
b. triamterene and hydrochlorothiazide.
c. amiloride and hydrochlorothiazide.
d. losartan and hydrochlorothiazide.
e. clonidine and chlorthalidone.

a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II and III

109. Imitrex is available as:


I. Nasal spray
II. Tablets
III. Injection
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

110. Ketorolac is a(n):


a. salicylate.
b. NSAID.
c. corticosteroid.
d. opioid.
e. benzodiazepine.
111. What is the maximum oral daily dose of ketorolac?
a. 20 mg
b. 40 mg
c. 50 mg
d. 100 mg
e. 250 mg
112. Which of the following conditions is NOT a
contraindication for ketorolac?
a. Hemorrhagic diathesis
b. Gastrointestinal perforation
c. Epilepsy
d. Renal failure
e. Breast-feeding
113. What is the brand name for latanoprost?
a. Toradol
b. Accuset
c. Xalatan
d. Conista
e. Zerolast
114. What is the correct daily topical dose of latanoprost
for the treatment of glaucoma?
a. 15 mcg
b. 15 mg
c. 1.5 mcg
d. 1.5 mg
e. 0.5 mcg

117. Combipres contains:


a. atenolol and chlorthalidone.
b. triamterene and hydrochlorothiazide.
c. amiloride and hydrochlorothiazide.
d. losartan and hydrochlorothiazide.
e. clonidine and chlorthalidone.
118. Tenoretic contains:
a. atenolol and chlorthalidone.
b. triamterene and hydrochlorothiazide.
c. amiloride and hydrochlorothiazide.
d. losartan and hydrochlorothiazide.
e. clonidine and chlorthalidone.
119. Dyazide contains:
a. atenolol and chlorthalidone.
b. triamterene and hydrochlorothiazide.
c. amiloride and hydrochlorothiazide.
d. losartan and hydrochlorothiazide.
e. clonidine and chlorthalidone.
120. Zosyn contains:
a. pipercillin and tazobactam.
b. ampicillin and sulbactam.
c. dalfopristin and quinupristin.
d. imipenem and cilastatin.
e. panipenem and betamipron.
121. What is the generic name for Crestor?
a. Carvedilol
b. Rosuvastatin
c. Venlafaxine
d. Pioglitazone
e. None of the above
122. Primaxin contains:
a. piperacillin and tazobactam.
b. ampicillin and sulbactam.
c. quinupristin and dalfopristin.
d. imipenem and cilastatin.
e. panipenem and betamipron.
123. Unasyn contains:
a. piperacillin and tazobactam.
b. ampicillin and sulbactam.
c. quinipristin and dalfopristin.
d. imipenem and cilastatin.
e. panipenem and betamipron.

49

50

SECTION I

PHARMACEUTICAL PRACTICE

124. Cyclobenzaprine is a:
a. benzodiazepine.
b. skeletal muscle relaxant.
c. tricyclic antidepressant.
d. GABA receptor agonist.
e. barbiturate.
125. What is the correct dose of cyclobenzaprine for
the treatment of pain associated with muscle
spasms?
a. 1530 mg daily
b. 510 mg daily
c. 25100 mg daily
d. 100250 mg daily
e. 100800 mg daily
126. What is the maximum length of time that
cyclobenzaprine should be used?
a. 7 days
b. 3 weeks
c. 2 months
d. 6 months
e. Indefinitely
127. Cyclobenzaprine:
a. has an onset of action of 1 hour.
b. has a duration of action of 1224 hours.
c. has a half-life of elimination of 837 hours.
d. a and b
e. a, b, and c
128. What is the correct dose of methocarbamol?
a. 1.5 g PO 4 times per day
b. 1 g IM every 8 hours
c. 13 g IV every 6 hours
d. All of the above
e. a and b
129. Side effects associated with methocarbamol include
all of the following EXCEPT:
a. bradycardia
b. urticaria
c. vertigo
d. jaundice
e. leukocytosis
130. What is the correct initial dose of amlodipine?
a. 0.5 mg bid
b. 5 mg bid
c. 10 mg bid
d. 5 mg qd
e. 10 mg qd
131. What is the maximum daily dose of
amlodipine?
a. 1 mg
b. 5 mg
c. 10 mg
d. 25 mg
e. 20 mg
132. Zolpidem is a(n):
a. opiate.

b.
c.
d.
e.

selective serotonin reuptake inhibitor.


hypnotic.
barbituate.
monoamine oxidase inhibitor.

133. What is the correct dosage of zolpidem?


a. 10 mg
b. 0.1 mg
c. 10 mcg
d. 0.1 mcg
e. 25 mg
134. What is the maximum daily dose of zolpidem?
a. 10 mg
b. 20 mg
c. 10 mcg
d. 20 mcg
e. 25 mg
135. Eszopiclone may cause all of the following adverse
effects EXCEPT:
a. unpleasant taste.
b. diplopia.
c. gynecomastia.
d. hallucinations.
e. headache.
136. Eszopiclone is used to treat:
a. depression.
b. bipolar disorder.
c. generalized anxiety disorder.
d. ataxia.
e. insomnia.
137. True or False: Terbutaline may cause hypokalemia.
a. True
b. False
138. True or False: Methylphenidate can be used to treat
narcolepsy.
a. True
b. False
139. True or False: Aspirin is safe to use during
pregnancy.
a. True
b. False
140. What is the correct initial dose of sulfasalazine in the
treatment of ulcerative colitis?
a. 0.5 g 34 times per day
b. 0.5 g once per day
c. 1 g 34 times per day
d. 10 g once per day
e. 25 g twice per day
141. What is the brand name of sulfasalazine?
a. Azulfidine
b. Asosulfide
c. Sulfasalicide
d. Sulfocyte
e. Sulfonate

CHAPTER 5

142. What is the generic name of Seroquel?


a. Amitriptyline
b. Aripiprazole
c. Quetiapine
d. Clozapine
e. Risperidone
143. What is the generic name of Abilify?
a. Amitriptyline
b. Aripiprazole
c. Quetiapine
d. Clozapine
e. Risperidone
144. What is the correct daily maintenance dose
of quetiapine for depression?
a. 100 mg
b. 150 mg
c. 300 mg
d. 500 mg
e. 600 mg
145. Of the following, which amount best represents an
initial total daily target for quetiapine in the
treatment of schizophrenia?
a. 100 mg
b. 150 mg
c. 300 mg
d. 500 mg
e. 600 mg
146. Side effects of quetiapine include all of the following
EXCEPT:
a. hypotension.
b. somnolence.
c. hypercholesterolemia.
d. bradycardia.
e. fever.
147. Carisoprodol is metabolized to which of the
following?
a. Meprobamate
b. Dopamine
c. Morphine
d. Phenobarbital
e. None of the above
148. What is a correct initial daily dose of aripiprazole for
the treatment of schizophrenia?
a. 15 mg per day
b. 30 mg per day
c. 45 mg per day
d. 90 mg per day
e. 200 mg per day
149. What is the correct initial daily dose of aripiprazole
for the treatment of bipolar disorder?
a. 15 mg per day
b. 30 mg per day
c. 45 mg per day
d. 90 mg per day
e. 200 mg per day

Dispensing

51

150. True or False: Aripiprazole has an onset of action


of 13 days.
a. True
b. False
151. True or False: Olanzapine is approved for
monotherapy of major depressive disorder.
a. True
b. False
152. Olanzapine:
a. may cause postural hypotension.
b. is available for oral, IM, and IV administration.
c. is a serotonin agonist.
d. is <50% protein bound in circulation.
e. has a half life of elimination of 1216 hours.
153. What is the correct initial dosage of clonidine for the
treatment of hypertension?
a. 0.1 mcg PO
b. 0.1 mg PO
c. 1 mg PO
d. 5 mg PO
e. 10 mg PO
154. True or False: Clonidine commonly causes
drowsiness.
a. True
b. False
155. Which of the following is FALSE concerning
rituximab?
a. It is an anti-CD20 monoclonal antibody.
b. It increases antibody-dependent cellular toxicity.
c. It can be used to treat rheumatoid arthritis.
d. B-cell levels return to normal 2 weeks after
treatment.
e. It may cause angioedema.
156. Memantine is a(n):
a. dopamine agonist.
b. norepinephrine antagonist.
c. acetylcholinesterase inhibitor.
d. N-methyl-d-aspartate receptor antagonist.
e. serotonin agonist.
157. What is the correct initial dose of memantine?
a. 0.5 mg per day
b. 2 mg per day
c. 2 mg three times per day
d. 5 mg per day
e. 5 mg two times per day
158. Paroxetine is used for:
I. Depression
II. Obsessive compulsive disorder
III. Parkinson disease
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

52

SECTION I

PHARMACEUTICAL PRACTICE

159. Singulair is available in which of the following


strength(s)?
I. 5 mg
II. 10 mg
III. 4 mg
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

160. OTC products containing minoxidil include:


I. solutions.
II. gel.
III. tablets.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

161. All of the following drugs are classified as DMARDs


EXCEPT:
a. Diflunisal
b. Penicillamine
c. Hydroxychloroquine
d. Methotrexate
e. Sulfasalzine
162. What is the correct initial dosage of transdermal
selegiline?
a. 6 mg per 12 hours
b. 6 mg per 24 hours
c. 6 mg per 48 hours
d. 3 mg per 24 hours
e. 10 mg per 48 hours
163. Donepezil is a(n):
a. acetylcholinesterase inhibitor.
b. dopamine antagonist.
c. GABA agonist.
d. GABA antagonist.
e. serotonin reuptake inhibitor.

167. Chloroquine is a:
a. peroxidase inhibitor.
b. aminoquindine.
c. n-alpha-quinine.
d. chlorhexadine.
e. aminoquinoline.
168. What is the correct dose of chloroquine for malaria
prophylaxis?
a. 500 mg per day
b. 500 mg bid
c. 500 mg tid
d. 500 mg per week
e. 500 mg one-time dose
169. Anturane is the U.S. brand name for:
a. Sulfinpyrazone
b. Allopurinol
c. Fenifibrate
d. Dolasetron
e. Auralgan
170. What is the correct dose of omeprazole for the
treatment of GERD?
a. 2 mg per day
b. 4 mg per day
c. 20 mg per day
d. 50 mg per day
e. 50 mcg per day
171. True or False: Omeprazole does NOT require
dosage adjustment in patient with renal
impairment.
a. True
b. False
172. Tinidazole is a:
a. nitroimidazole.
b. chloroquinolone.
c. amebicide.
d. a and b
e. a and c

164. How is donepezil supplied?


a. 5 or 10 mg
b. 10 or 20 mg
c. 5 or 15 mg
d. 100 or 250 mg
e. 250 or 500 mg

173. What is the correct dosage of tinidazole for the


treatment of bacterial vaginosis?
a. 2 g per day for 5 days
b. 2 g per day for 2 days
c. 20 g per day for 5 days
d. 200 g per day for 2 days
e. 200 mg per day for 5 days

165. For the treatment of what condition(s) is/are


donezepil approved?
a. Major depression
b. Bipolar disorder
c. Dementia
d. a and b
e. a and c

174. Side effects of amphotericin B include all of the


following EXCEPT:
a. hypotension.
b. tachypnea.
c. polycythemia.
d. hypomagnesemia.
e. hypokalemia.

166. True or False: Chloroquine is approved for the


treatment of extraintestinal amebiasis.
a. True
b. False

175. What is the correct dose of clotrimazole for


oropharyngeal candidiasis prophylaxis?
a. 10-mg troche once per day
b. 10-mg troche three times per day

CHAPTER 5

c.
d.
e.

10-mg troche five times per day


10-mg troche six times per day
10-mg troche single dose

176. What is the correct dose of clotrimazole for


treatment of active oropharyngeal candidiasis?
a. 10-mg troche once per day
b. 10-mg troche three times per day
c. 10-mg troche five times per day
d. 10-mg troche six times per day
e. 10-mg troche single dose
177. True or False: Clotrimazole is available for
administration as an oral troche, topical cream,
topical solution, and vaginal cream.
a. True
b. False
178. Clotrimazole:
a. is excreted predominantly in the feces.
b. is absorbed into systemic circulation following
topical application.
c. has a time to peak serum concentration of
12 days following oral troche.
d. a and b
e. a, b, and c
179. The federal transfer auxiliary label is required for
what schedule of medication?
a. Schedule II to IV
b. Schedule II only
c. All schedule drugs
d. Schedule II and III only
180. Pregabalin is structurally related to which of the
following?
a. Gabapentin
b. Carbamazepine
c. Felbamate
d. Tiagabine
e. Levetiracetam
181. Thiopental:
a. is a potent analgesic.
b. increases cerebral activity as measured by EEG.
c. produces respiratory depression dosedependently.
d. is only useful as a skeletal muscle relaxant.
e. should not be used in patients with epilepsy.

Dispensing

53

184. What is a brand name for tacrolimus?


a. Prograf
b. Propecia
c. Proscar
d. Protonix
185. Which of the following is (are) classified as an
antiepileptic agent?
I. Kaletra
II. Lamictal
III. Mysoline
a.
b.
c.
d.
e.

I only
III only
I and II
II and IIII
I, II, and III

186. Which of the following is a contraindication for


alosetron use?
a. Diarrhea
b. Constipation
c. Renal impairment
d. Asthma
e. Diabetes
187. Which of the following are the correct contents and
quantity of medication contained in each
teaspoonful of Tussionex?
a. Hydrocodone 2.5 mg and diphenhydramine
25 mg
b. Hydromorphone 2.5 mg and diphenhydramine
25 mg
c. Hydromorphone 5 mg and chlordiazepoxide
2.5 mcg
d. Hydrocodone 10 mg and diphenhydramine
50 mg
e. Hydrocodone 10 mg and chlorpheniramine
8 mg
188. What percent chlorhexidine concentration is in the
antimicrobial agent Hibiclens?
a. 4%
b. 10%
c. 14%
d. 15%
e. 25%

182. What are the active ingredients in Lotrel?


a. Amlodipine and atorvastatin
b. Lisinopril and hydrochlorothiazide
c. Amlodipine and benazepril
d. Hydralazine and isosorbide dinitrate

189. What is the generic name of Bactroban?


a. Vistaril
b. Cetirizine
c. Hydroxyzine
d. Mupirocin
e. Homatropine

183. Prevpac contains which of the following drugs?


a. Amoxicillin, clarithromycin, and lansoprazole
b. Ampicillin, clarithromycin, and omeprazole
c. Amoxicillin, azithromycin, and lansoprazole
d. Amoxicillin, clarithromycin, and omeprazole
e. Ampicillin, azithromycin, and lansoprazole

190. What is the generic name for Detrol?


a. Torsemide
b. Tolterodine
c. Tolazamide
d. Topiramate
e. Tolmetin

54

SECTION I

PHARMACEUTICAL PRACTICE

191. Which of the following statements are true regarding


metformin?
I. It may cause renal failure.
II. It is a hypoglycemic agent.
III. The maximum daily dose is 2550 mg/day.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and II

192. What is the generic name for Glynase?


a. Glyburide
b. Acarbose
c. Rosiglitazone
d. Glimepiride
e. Chlorpropamide
193. Cosopt is made of which of the following ingredients?
a. Brimonidine and timolol
b. Dorzolamide and timolol
c. Epinephrine and pilocarpine
d. Carbachol and dorzolamide
e. None of the above
194. True or False: Oxymetazoline nasal spray should be
used for at least 2 weeks for the patient to
experience relief.
a. True
b. False
195. Timolol:
a. may cause conjunctivitis.
b. has a duration of action of 12 hours.
c. has a peak effect 6 hours after topical application.
d. a and b
e. a and c
196. Which of the following medication suspensions do
not need to be refrigerated?
I. Zithromax
II. Augmentin
III. Biaxin
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

197. Home ovulation test kits detect which of the


following hormones?
a. LH
b. FSH
c. hCG
d. TSH
e. None of the above
198. Which of the following medications should be
avoided in pregnant women due to its properties as
an abortifacient?
a. Misoprostol
b. Piroxicam

c.
d.
e.

Aspirin
Tetracycline
Phenytoin

199. Intermittent claudication is treated with which of


the following?
I. Diovan
II. Trental
III. Pletal
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

200. What is the generic name for Cozaar?


a. Hydrochlorothiazide
b. Lisinopril
c. Losartan
d. Enalapril
e. a and c
201. What are the active ingredients of Symbyax?
a. Fluoxetine and olanzapine
b. Duloxetine and venlafaxine
c. Paroxetine and quetiapine
d. Citalopram and olanzapine
e. Fluoxetine and clozapine
202. Enbrel works by:
a. T-cell deactivation.
b. TNF antagonism.
c. stimulation of red blood cell production.
d. gene fusion.
e. None of the above
203. Azithromycin is available in which of the following
formulations?
I. Oral tablets
II. Injection
III. Oral suspension
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

204. How frequent should the tetanus booster vaccine be


administered?
a. Every 2 years
b. Every 5 years
c. Every 10 years
d. Every 20 years
e. Every 30 years
205. How many mg of medication are in one teaspoonful
of Naprosyn suspension?
a. 125 mg/5 mL
b. 100 mg/5 mL
c. 50 mg/5 mL
d. 25 mg/5 mL
e. None of the above

CHAPTER 5

206. Which is the generic name for Norflex?


a. Diclofenac
b. Ibuprofen
c. Orphenadrine
d. Cyclobenzaprine
e. Oxaprozin
207. Atacand can best be described as an:
a. ACE inhibitor
b. Diuretic
c. Alpha-1 adrenergic blocker
d. Beta blocker
e. Angiotensin II receptor blocker
208. Which of the following drug(s) is (are) an MAO
inhibitor?
I. Parnate
II. Eldepryl
III. Mobic
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

Dispensing

55

209. Select the available dosage strength(s) of oral Actos:


I. 30 mg
II. 45 mg
III. 60 mg
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

210. Which of the following drug(s) is/are available as


metered dose inhalers (MDIs)?
a. Aerobid
b. Serevent
c. Pulmicort
d. Advair
e. Foradil
211. The dose of Accolate for asthma is:
a. 2 mg BID
b. 20 mg BID
c. 200 mg QD
d. 200 mg BID
e. 2g QD

..................................................

Patient Education

CHAPTER

...................................................................................................................................................................

I.

Provide health care information regarding the


prevention and treatment of diseases and medical
conditions, including emergency patient care.
A. Educate patients regarding their disease states and
conditions.
1. Patient-appropriate terms: Medical terminology
should be translated to plain (simple) language
to simplify concepts for the patient and to
promote understanding. See Table 6-1 for
common examples.

Table 6-1

Examples of Consumer Terms to be used


in Patient Education

Medical Term

Consumer Term

Analgesic
Arrhythmia
Buccal

pain reliever
irregular heartbeat
between the cheek and the
gum
water pill
liver
high cholesterol
high blood sugar
high blood pressure
low blood sugar
swelling
(drug) breakdown
for the eye
for the ear
fainting
preventative
itching
kidney
salt solution
under the tongue
under the skin
applied to the skin
absorbed through the skin

Diuretic
Hepatic
Hypercholesterolemia
Hyperglycemia
Hypertension
Hypoglycemia
Inflammation
Metabolism
Ophthalmic
Otic
Postural hypotension
Prophylaxis
Pruritus
Renal
Saline
Sublingual
Subcutaneous
Topical
Transdermal

B. Steps in counseling patients regarding medication


use
1. Establish relationship, show interest in patient
(verbal and nonverbal).
2. Use two patient identifiers for verification
(e.g., address and date of birth).
56

3. Ask about allergies (e.g., drug, food, contact,


and environmental).
4. Ask what over-the-counter (OTC), herbals/
supplements, and other prescriptions the patient
is taking (patients may not fill all prescriptions at
the same pharmacy). Additional medical
conditions may also be considered as needed
(i.e., a patient with asthma receiving a beta
blocker with beta-2 action).
5. Ask the patient what they know about their
medications and why they are being
prescribed (i.e., the medications use,
expected benefits, and action).
6. Discuss with the patient what their doctors
told them regarding their medications, how to
use them, and what to expect.
7. Open the medication container and show the
patient what the medication looks like or
demonstrate use; the patient may not be
expecting a generic substitution, and they can
also verify correct product.
8. Discuss how to take the medication.
9. Discuss when to take and how long to take the
medication.
10. Discuss what to do if a dose is missed (take
missed dose immediately or skip the missed
dose and wait until new administration time).
11. Discuss any special precautions to follow.
12. Discuss foods, alcoholic beverages, OTC,
drugs, or supplements to be avoided.
13. Discuss how the patient will know the
medication is working.
14. Discuss how to store the medication.
15. Discuss if the prescription can be refilled, and
if so, when.
16. Instruct on beneficial nondrug activities as
appropriate.
17. Verify the patients knowledge and
understanding by asking the patient to repeat
the given information.
18. Ask patients what questions they have.
19. End the counseling session by repeating your
name and the pharmacys telephone number.
20. Document the counseling session.
C. Important patient considerations for counseling
1. New patients or those receiving a medication for
the first time (including transfer prescriptions)
2. Confused patients and their caregivers
3. Patients who are vision or hearing impaired,
handicapped, or in need of special assistance

CHAPTER 6

4. Patients with low functional health literacy


5. Patients whose profile shows a change in
medications or dosing
6. Patients whose overall appearance has
worsened due to their condition(s)
7. Patients who appear to be in distress
8. Patients who speak a different language
9. Elderly patients
10. Children and their parents
11. Patients receiving medication with special
storage requirements, complicated directions,
significant side effects, or narrow therapeutic
ranges [e.g., digoxin and anti-epileptic drugs
(AED)].
12. Patients who cannot afford their medications
13. Patients receiving oral contraception
regarding the risk of cardiovascular disease
(CVD) if they smoke or are older than 35 years
14. Patients receiving oral contraception and
select antibiotic medications (contraception
failure may occur)
15. Patients receiving warfarin should be aware of
the signs and symptoms of bleeding and blood
clotting.
16. Patients using OTC medications that contain
the same ingredients as their prescription
medications (e.g., Vicodin and Tylenol
[acetaminophen])
D. Other Concepts to discuss with patients and
health care professionals
1. Adverse reaction concerns:
a. An adverse drug event (ADE) is any
undesirable experience associated with the
use of a medical product in a patient. Most
potential adverse drug events can be
prevented; however, an unpreventable
adverse drug event is considered an adverse
drug reaction.
b. Most adverse drug reactions (ADR) are
common, relatively mild, and disappear
when the drug is discontinued or the dose is
changed. Common mild drug reactions
include loss of appetite, bloating, nausea,
and constipation. Serious drug reactions are
those that cause death, disability or
congenital anomaly or that require
hospitalization. Serious ADR may require
medical intervention to prevent further
damage or impairment.
c. The following examples illustrate various
adverse drug events:
(a) Sulfonamide antibiotics versus other sulfacontaining products (i.e., cross-sensitivity
reactions rather than sulfa-allergy)
(b) Risk of Reye syndrome in children taking
salicylate containing medications and
with concurrent viral illness
(c) Cross-sensitivity reaction potential
between penicillins and cephalosporins
(d) Cross tolerance (or lack of tolerance)
within drug classes (e.g., statins,
angiotensin-converting enzyme [ACE]
inhibitors, and triptans)

Patient Education

57

d. Adverse events that are common that


require minimal intervention (e.g., postural
hypotension when starting beta blockers;
constipation for opioid analgesics), and that
require immediate attention (e.g., StevensJohnson syndrome for sulfonamide
antibiotics; tendinitis/tendon rupture for
quinolones).
e. True allergy (e.g., anaphylaxis) versus ADR
(nausea with opioid analgesics or oral
penicillins); including what reactions allow a
rechallenge or desensitization of the drug
1) Types of allergic reactions:
a) Type I reaction (immediate):
anaphylaxis, Immunoglobin E (IgE)
mediated (penicillin)
b) Type II reaction: cytotoxic,
Immunoglobin M (IgM) or
Immunoglobin G (IgG) mediated
(penicillin, quinidine)
c) Type III reaction: immune complex
mediated, IgG mediated (phenytoin,
sulfonamides, radiocontrast)
d) Type IV reaction: delayed
hypersensitivity, T-cell mediated
(tuberculosis skin test)
2. Examples of appropriate drug use
a. Spacing antacids and calcium containing
products from certain medications (e.g.,
select antibiotics, such as tetracyclines,
quinolones)
b. Taking drugs at appropriate times
c. Spacing of medication administration times
for peak effects or to avoid toxic effects (e.g.,
aspirin shortly before or long after a
nonsteroidal anti-inflammatory drug)
d. Dietary restrictions for monoamine oxidase
inhibitor (MAOI), warfarin, or quinolones (no
tyramine-containing products [cheese, wine,
red meats], do not alter the intake of the
amounts of vitamin K containing products,
and separate dairy intake from the time of
administration, respectively)
e. Understanding Two tabs twice daily
4 tablets a day total not 2 tablets each day;
and similar multiplying concepts
f. Importance of finishing an antibiotic course
of treatment to ensure therapeutic response
and avoid recurrence of infection
g. Not using corticosteroid and long-acting
beta-agonist medication for acute asthma
symptoms
h. How to use inhalers, nebulizers, injectable
medications, insulin pens, blood glucose
monitors, and other devices
i. Not to discontinue medications; consult the
prescriber first.
j. Understand cautions needed with the use of
medications in special populations (e.g.,
pediatric, geriatric, patients with organ
failure, patients with immunosuppression,
pregnant or lactating women)
k. Use of insulin products

58

II.

SECTION I

PHARMACEUTICAL PRACTICE

l. Proper disposal of needles and expired


medications and other safety measures such
as storage that are related to accidental
exposure or poison prevention
m. Compliance improvement strategies (dose
timing, pill boxes, and reminder timers)
n. Importance of reporting adverse drug
reactions (e.g., MedWatch)
3. Product selection for patients
a. Brand and generic drugs
b. Over-the-counter (OTC) and dietary
supplements
4. Possibly confusing concepts for patients
a. Brand versus generic drugs
b. The difference among drug tolerance,
substance dependency, and addiction
(including the upregulation and
downregulation related to nonaddictive
substances such as beta blockers)
c. Evidence-based medicine versus faith-based
medicine (see also Section III)
d. Potassium (K) versus Vitamin K
e. Avoiding versus limiting intake
f. Vaccinations: Which populations/ages/
international travelers require what
vaccines; concerns about autism in
conjunction with routine immunizations
E. Emergency/nonself-care considerations
Patients who present to the pharmacy on an
ambulatory basis may need medical treatment versus
pharmacist intervention. Here are some
considerations when self-treatment is no longer
acceptable and when patients should contact their
primary care physician or go to the emergency
department.
1. Generally managed by primary care physician
a. Mild-to-moderate side effects including
constipation, sedation, headache
2. Example emergency situations
a. Uncontrolled bleeding (possibly from trauma
or antiplatelet therapy)
b. Hypersensitivity reaction to any drug
c. Fainting (related to antihypertensives,
erectile dysfunction medications, etc.)
d. Hypoglycemia (low blood sugar, too much
insulin, or hypoglycemic use)
e. Diabetic ketoacidosis (DKA)
f. Acute asthma exacerbation not responsive
to rescue inhaler
g. Angina not responsive to nitroglycerin after
5 minutes of first administration
h. Accidental ingestion of toxic substances
i. Sudden unilateral neurologic symptoms
consistent with stroke
j. Symptoms consistent with serious local (e.g.,
cellulitus or gangrene) or systemic infection
(e.g., excessive purulent cough - potential
pneumonia)
Provide health care information regarding nutrition,
lifestyle, and other nondrug measures that are
effective in promoting health or preventing or
minimizing the progression of a disease or medical
condition

A. Patient monitoring based on drug or disease state


1. Hypertension
a. Blood pressure; note different ranges and
goals for patients with compelling
indications (e.g., diabetes, chronic kidney
disease, stroke, heart failure, coronary artery
disease, or post-myocardial infarction)
b. Recording of blood pressure (selfmonitoring)
c. Therapeutic lifestyle changes; diet (e.g.,
limit salt intake) and exercise
2. Diabetes
a. Control parameters (blood sugar
90130 mg/dL, HbA1c < 7%)
b. Recording of blood glucose (selfmonitoring)
c. Foot inspection
d. Vision exams
e. Blood pressure
f. Influenza vaccination
3. Asthma/COPD
a. Rescue inhaler use frequency (when to seek
professional care for exacerbations)
b. Pulmonary function testing
c. Annual influenza vaccination
4. Headache/epilepsy
a. Headache/seizure frequency
b. Patient documentation and avoidance of
precipitating factors (light/sound/mood/
surroundings)
5. Antiretroviral therapy for HIV/AIDS
a. Nutritional status
b. Laboratory testing (CD4 cell count/RNA
copies)
c. Transmission reduction (abstinence,
condoms, no needle sharing), also applicable
for hepatitis viruses, HBV and HCV
d. Refill verification/medication compliance
e. Drug toxicity monitoring
6. Mental disorders
a. Movement disorders (antipsychotics)
b. Glucose control (antipsychotics)
c. Triglyceride levels (antipsychotics)
d. Drug serum levels or recommended
laboratory testing (e.g., antiepileptic drugs
[AED], lithium, clozapine)
e. Suicide risk (AED, lithium, antidepressants,
antipsychotics)
f. Appropriate psychotherapy
g. Healthy activities: meditation, yoga, etc.
7. Anticoagulation therapy
a. Dietary considerations (consistency with
foods containing vitamin K)
b. Interactions with herbal supplements (e.g.,
garlic)
c. Anticoagulation clinic
d. Monitoring for unusual bleeding (e.g.,
bleeding gums, unusual bruising, blood in
urine or stool)
8. Osteoporosis
a. How to take bisphosphonates, which can
cause serious problems in the stomach or
esophagus

CHAPTER 6

b. Take each dose with a full (8 oz) glass of


water (plain water, not mineral water)
c. Patient must stay upright for at least 30
minutes after taking this medication.
d. Take the medication first thing in the
morning, at least 30 minutes before eating
or drinking other substances or before
taking any other medication.
e. Importance of calcium and vitamin D
supplementation
9. Hyperlipidemia
a. Report any muscle pain or weakness
b. Take statins at appropriate time (some
taken at bedtime or at evening meal for
maximal physiologic effect on cholesterol
synthesis)
10. Smoking cessation counseling
a. Nonpharmacologic treatment is a five-step
process that includes:
1) Asking every patient about tobacco use
2) Advising all smokers to quit
3) Assessing smokers willingness to make
an attempt to quit
4) Assisting smokers with treatment and
referrals
5) Arranging follow-up contacts
b. Pharmacologic treatments (prescription
and OTC)
B. Preventative health measures
1. Preventive and protective sexual behaviors
a) Birth control
b) Prevention of sexually transmitted disease
(STD)
2. Immunization against communicable diseases:
a) Mumps
b) Measles
c) Rubella
d) Tetanus and/or pertussis
e) Diphtheria
f) Rotavirus
g) Human papilloma virus (HPV), causing
cervical cancer and genital warts)
h) Polio
i) Haemophilus influenzae Type b (Hib)
j) Varicella zoster virus, (VZV) (chicken pox
and shingles)
k) Hepatitis A virus (HAV)
l) Hepatitis B virus (HBV)
m) Meningococcal infection
n) Influenza
o) Pneumococcal infection
III. Provide information regarding the documented uses,
adverse effects, and toxicities of dietary supplements.
A. Explaining basic differences between modern
medicine (allopathic) and complementary
(homeopathic, Chinese medicine, etc.)
1. Allopathic medicine refers to modern
conventional Western medicine.
2. The term complementary and alternative
medicine (CAM) is generally regarded as
encompassing a broad group of healing
philosophies, diagnostic approaches, and
therapeutic interventions that do not belong to

Patient Education

59

the dominant (conventional) Western health


system.
a. CAM therapies are divided into five
categories, or domains:
1) Alternative medical strategies (e.g.,
homeopathic medicine, traditional
Chinese medicine)
2) Mind-body interventions (e.g., meditation,
prayer)
3) Biologically based therapies (e.g., dietary
supplements, herbal products)
4) Manipulative and body-based methods
(e.g., chiropractic manipulation, massage)
5) Energy therapies (e.g., qi gong, reiki)
B. Selecting dietary supplements
1. Not all products have the stated doses or purity
that the label may suggest. The manufacturers
of herbals/supplements (products that have
Supplement Facts on the back) decide if they
are willing to be inspected by the FDA to reach
Good Manufacturing Practice (GMP) standards.
Not all companies are willing to do this, but
those who pass inspections are granted USP
status. Alternatively, all medications labeled as
drugs (prescription and OTC medications
containing Drug Facts on the back) must pass
GMP standards. Products are assessed for
purity, potency, and the stated strength.
C. Deciding if therapy is appropriate
1. Patients should be evaluated by their physician
to decide if supplemental therapy is necessary.
Most patients with an adequate diet do not
need supplements added to their diet. Patients
should be aware of multisourcing their vitamins
(dietary intake and supplements) to avoid
exceeding the recommended dietary intakes
(RDI).
2. Certain patients, however, may need
supplements added to their diets based on well
documented conditions and drug use:
a. Folic acid for pregnant women to prevent
neural tube defects
b. Pyridoxine (vitamin B6) for patients on
isoniazid to prevent peripheral neuropathy
c. Thiamine (vitamin B1) in alcoholics to
prevent encephalopathy
d. Vitamin D requirements in patients with
select bone diseases
IV. Provide information regarding the selection, use, and
care of medical/surgical appliances and devices, selfcare products, and durable medical equipment, as
well as products and techniques for self-monitoring of
health status and medical conditions.
A. Drug administration considerations
1. Description of inhaler use (which is brand
specific), with and without a spacer
a. Shake suspensions/aerosol solutions (not
tablets or powders) before use
b. Prime suspensions/aerosol solutions before
first use, and if they have not been used for a
period of time (actual length of time where
product requires re-priming is product/
manufacturer specific)

60

SECTION I

2.

3.

4.

5.

PHARMACEUTICAL PRACTICE

c. Hold the inhalation for an appropriate


amount of time and the appropriate spacing
between multiple inhalations
d. Rinse the mouth after inhalation to prevent oral
thrush and hoarseness from corticosteroids
e. Routinely clean the device (not for powders
or tablet formulations and not the canister)
as directed
f. Do not share: for individual use only
Description of eye drop or ointment
administration
a. Washing hands before and after use
b. Gently holding open the lower eyelid creating
a pocket where the drop should be inserted
c. Not touching the dropper to the eye or tube
to the eyelid
d. Keeping the head tilted
e. After administration, with a tissue gently
wiping away excess moisture or ointment
from around the eye(s)
f. Separation of drops for multiple drops per
dose and between different medication eye
drops; use of lacrimal occlusion during
administration to prevent systemic
absorption (e.g., ophthalmic beta-blockers)
g. Do not share: for individual use only
h. Temporarily removing or disposing contacts
before administration
i. Use of eye dropper aids
Description of ear drop administration
a. Washing hands before and after use
b. Warming drops by rolling between the
hands, not a heating device; shake
suspensions well before each use.
c. Not touching the dropper to the ear
d. Keeping the head in a tilted position for
adequate entry into the ear canal
e. Gently pulling the ear up and back (adults)
or down and back (children 8 and younger)
f. Covering the ear with the tragus (small portion
of cartilage, just outside the opening) for
about 5 minutes after administration
g. Do not share: for individual use
Description of nasal spray administration
a. Washing hands before and after use
b. Prime spray pump (if required) before first
use, and if they have not been used for a
period of time (actual length of time elapsed
when product requires re-priming is
product/manufacturer specific)
c. Blowing nose gently before spray and not
blowing nose immediately after use
d. Direct spray back and away from nasal septum
e. Wiping nozzle after use
f. Do not share: for individual use only
Insulin administration
a. Wash hands before and after administration
b. Roll insulin vial between hands; preparation
of insulin pen or other insulin devices
c. Inject insulin in the subcutaneous fat (the
layer of fat just below the skin)
d. Pinch up a fold of skin and insert the needle
at 90 to the skin fold. Inject at 45 in areas
that have less fat

6.

7.

8.

9.

e. Rotate injection sites to maximize rate


absorption and prevent lipohypertrophy
(enlargement of subcutaneous fat)
f. Differences between products (basal/bolus)
and timing (daily/before meals)
g. Mixing insulins
h. Insulin of NPH type may be mixed with rapidacting insulin aspart (Novo-Log) and insulin
lispro (Humalog) and regular insulin
1) Mixing insulin of Lente type (e.g.,
Humulin L) with regular insulin may
result in loss of short-acting effect
2) Order for mixing insulins is clear
before cloudy (regular insulin drawn
first, followed by intermediate-acting
insulin)
i. Syringe disposal
j. Glucose meter device differences and use
1) Testing frequency
2) Required drop size
3) Alternate site testing
4) Display size
5) Coding
6) Memory and ability to connect with a
personal computer (PC)
Epinephrine and glucagon pen/rescue device
use
a. Carry at least two EpiPens at all times
b. Proper use of glucagon for emergency
hypoglycemia typically requires training of
companion, family, or other caregiver
Transdermal patch use
a. Application sites and site rotation
(application sites are product specific)
b. Hair-free areas (which are not recently
shaved)
c. Avoiding areas with broken or irritated skin
d. Removal and safe disposal
e. Application frequency
f. Avoiding tight clothing and heat application
Administration of rectal enemas and
suppositories
a. Lying on the left side for product
administration
b. Removal of suppository from the wrapper
c. Lubrication of enema applicators, not
suppositories
d. Wait times after administration
Product specific considerations. Examples:
a. Nuva-Ring: product-switching
considerations (i.e., if a back-up method is
necessary, how soon should the new
product be initiated)
b. Nitroglycerin ointment: apply measured
dose only to a 200  300 area using the
provided ruler; application only to chest
or back
c. Sublingual nitroglycerin (Note: patients may
not experience a tingling sensation with
newer products; if no relief after first dose,
get emergency help and continue acute relief
instructions.)
d. Nicorette gum (place the chewing gum
between the cheek and gum once peppery

CHAPTER 6

taste is noted, do not continue to chew it;


resume chewing when tingle diminishes)
e. EpiPen (single use, carry extra device for
emergency purpose)

Bibliography
Ball AM, Smith KM: Optimizing transdermal drug therapy,
Am J Health Syst Pharm 65:1337, 2008.
PEIPB: Guidelines on counseling. http://www.napra.org/
pdfs/provinces/pe/Guidelines-on-Counseling.pdf
Accessed September 22, 2008.
Lexi-Comp Online: Nitroglycerin [patient education leaflets adult]. http://online.lexi.com xxx. Accessed September
23, 2008.
AHFS MedMaster: How to use metered dose-inhalers. http://
www.safemedication.com/Administer/DoseInhalers.pdf
Accessed July 2009.

REVIEW QUESTIONS
(Answers and Rationales on page 333.)
1. A person with type 1 diabetes is currently using
insulin. What should the pharmacist advise?
I. Insulin may be unrefrigerated for 28 days.
II. Avoid smoking.
III. Do not shake cloudy insulin; roll in hands.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

2. When a patient is being counseling on the use of


Nexium, which of the following is most appropriate
for the pharmacist to state?
a. Take this medication once daily, 1 hour before a
meal.
b. This medication may cause sedation.
c. This medication is used to treat your toenail
infection.
d. This medication is used for your high blood
pressure condition.
3. An asymptomatic patient who started taking atenolol
goes to the pharmacy with a blood pressure of 132/78
and pulse of 54 beats per minute? Which of the
following is the most appropriate action?
a. Advising the patient that these are normal values
and not to worry
b. Calling the physician and suggesting that
metoprolol might have a less pronounced effect
on the patient s heart rate
c. Asking the patient if he has noted any dizziness
on standing or decreased exercise tolerance
d. Advising the patient to discontinue atenolol
immediately
4. Which show-and-tell question(s) should a
pharmacist ask when dispensing a refill?
I. What do you take this medication for?

Patient Education

61

II. How do you take this medication?


III. What kind of problems have you been
experiencing while taking this medication?
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

5. Which of the following counseling points should


be made regarding the administration of Metamucil?
a. Mix the granules with one gallon of water, stir,
and store in the refrigerator; drink when
needed.
b. Mix the granules with eight ounces of water, stir,
and let stand for an hour; then drink.
c. Mix the granules with eight ounces of water, stir,
and drink immediately.
d. Swallow a teaspoonful of granules with an eightounce glass of water.
6. What are the possible side effects of Ritampin about
which the pharmacist should counsel the patient?
a. This medication can cause stiffness in joints.
b. This medication can cause the urine to appear
dark.
c. Wear sunscreen outside while taking this drug.
d. Report flu-like symptoms to your doctor.
7. A 57-year-old patient with long-standing COPD takes a
new prescription for an ipratropium (Atrovent)
inhaler to the pharmacy. The pharmacists medication
record shows that the patient is also using an
albuterol inhaler as needed. Which of the following
indicates that the patient understands how to
incorporate the Atrovent into her regimen?
a. She substitutes the Atrovent for the albuterol.
b. She uses the Atrovent inhaler as needed for
wheezing.
c. She uses the Atrovent inhaler four times a day.
d. For acute attacks, she should use the albuterol
inhaler initially, then the Atrovent, as needed
for wheezing.
8. A 48-year-old patient with stable COPD has a refill
prescription for Combivent and a new prescription
for Spiriva. Which of the following actions
indicates that the patient understands the COPD
regimen?
a. She uses the Combivent inhaler every morning
and evening.
b. She uses the Spiriva as needed for wheezing.
c. She uses the Combivent inhaler as needed for
wheezing.
d. She takes the Spiriva capsules by mouth.
9. During medication counseling for Diovan tablets,
which of the following statements would verify that
the patient has a good understanding of the possible
side effects of the drug?
a. I might have bladder spasms with this
medication.

62

SECTION I

b.
c.
d.

PHARMACEUTICAL PRACTICE

I might get dizzy with this medication.


I might get constipated while taking this
medication.
My vision might turn yellow with this medication.

10. Which of the following would show that a patient


understands why he is taking Abilify?
a. I have bipolar disorder.
b. I have obsessive compulsive disorder.
c. I have postherpetic neuralgia.
d. I have severe diabetic peripheral neuropathy.
11. Which questions should a pharmacist ask a patient
when verifying the medication at pick-up?
a. What OTC medicines do you take?
b. What doctor prescribed you this medication?
c. To make sure your medication is effective, how it
should be taken?
d. Do you have any allergies?
e. None of the above
12. When counseling a patient, it is important to include
take on an empty stomach for which of the
following medications?
I. Saquinavir
II. Alendronate
III. Levothyroxine
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

13. A mother comes to the pharmacy with questions


about diaper rash. What counseling points would a
pharmacist provide?
a. Make frequent diaper changes.
b. Use breathable disposable diapers.
c. Expose skin under diaper to open air.
d. Use barrier creams such as zinc oxide.
e. All of the above
14. Which of the following questions should a pharmacist
ask a patient when dispensing a new prescription?
I. What did the doctor tell you the medication is for?
II. How did the doctor tell you to take this
medication?
III. What did the doctor tell you to expect when
taking this medication?
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

15. What should you advise a patient with diabetes to do


if he/she feels symptoms of low blood sugar?
I. Drink a glass of orange juice.
II. Test blood glucose.
III. Within 30 minutes after symptoms subside, eat a
light snack.

a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

16. A patient goes to the pharmacy with a prescription


for Prandin. What should the pharmacist tell the
patient when dispensing the filled prescription?
a. Take on an empty stomach.
b. Take before meals.
c. It may cause drowsiness.
d. If you miss a meal, take between meals.
17. Which of the following are counseling points
regarding the use of metered-dose inhalers?
a. Shake the canister or inhaler in place for 510
seconds before use.
b. Hold breath for 10 seconds to allow medicine to
reach the lungs.
c. Tilt head back slightly and begin to inhale slowly.
d. Close your lips around the mouthpiece.
e. All of the above
18. Which of following describes proper technique for
administering eye drops?
I. With the forefinger, pull down the lower eyelid to
form a pocket.
II. Touch the tip of the dropper against the eye
when administering the drops.
III. Immediately after administering the drops,
press a forefinger against the inside corner of
the eye.
a.
b.
c.
d.
e.

I only
III only
I and II
I and III
I, II, and III

19. Which of following describes proper technique for


using a peak flow meter?
I. Before using the peak flow meter, fully inflate the
lungs by taking a deep breath.
II. Do not put the mouthpiece of the peak flow
meter into the mouth.
III. With as much force as possible, blow out as
quickly as possible.
a.
b.
c.
d.
e.

I only
III only
I and II
I and III
I, II, and III

20. A 40-year-old man is going to a wedding this weekend.


He is afraid he may experience heartburn and wants
to try Gaviscon. Which of the following should a
pharmacist tell him?
I. If you have milk or dairy allergies, you should
avoid this medication.
II. Do not take more than 10 mg.
III. Do not use for more than 2 weeks.

CHAPTER 6

a.
b.
c.
d.
e.

I only
III only
I and II
I and III
I, II, and III

21. A patient is thinking about trying the EZ Detect fecal


occult blood test. What should the pharmacist tell
him about using the test?
I. Avoid aspirin 2 days before use.
II. Urine may alter the results.
III. Toilet bowl cleaners may cause false positive
results.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

22. A 58-year-old man recently started using Niaspan.


He complains that he is experiencing flushing. What
should a pharmacist recommend for this patient?
I. Take Niaspan first thing in the morning on an
empty stomach to avoid flushing.
II. Take aspirin 325 mg 30 minutes before taking
Niaspan.
III. Avoid alcohol or hot drinks around the time of
Niaspan administration.
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

23. A 50-year-old woman asks a pharmacist about what


she can to do prevent osteoporosis. What should the
pharmacist recommend?
I. Avoid weight-bearing exercises.
II. Consume at least 1200 mg per day of calcium and
8001000 IU of vitamin D.
III. Limit alcohol intake.
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

24. A 62-year-old woman goes to the pharmacy with a


prescription for Fosamax. What should the
pharmacist tell her about its use?
I. Take the medication with food and a full glass of
water.
II. Lie down for at least 30 minutes after swallowing
the tablet.
III. Swallow the tablet whole.
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

Patient Education

63

25. A patient goes to the pharmacy with a new


prescription for Miacalcin nasal spray. What should
the pharmacist tell the patient when dispensing the
medication?
I. After 30 doses, each spray may not deliver the
correct amount.
II. The pump should be primed before each daily
dose only.
III. Store unopened bottles in refrigerator.
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

26. A 16-year-old girl has a prescription for Servent


Diskus. What should the pharmacist tell her?
I. The dose indicator shows how many doses are
left.
II. Do not breathe out into the mouthpiece.
III. Close the Diskus after use so it is ready for the
next dose.
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

27. When counseling a patient about emergency


contraception, which of the following is an accurate
statement to make?
a. Emergency contraception may be used as a
primary means of contraception.
b. Plan B emergency contraception is no longer
sold in the United States.
c. Emergency contraceptive pills can delay
ovulation.
d. Emergency contraceptive pills take at least
72 hours to work.
e. Progestin only formulations, like plan B, are not
better tolerated than estrogen/progestin
combination regimens.
28. A patient has been counseled on the appropriate use
of his new prescription for risedronate. Which of the
following statements would verify that the patient has
a good understanding of the consultation information
that the pharmacist has provided?
I. This medication will help with my Parkinson
symptoms.
II. This medication will help with my osteoporosis.
III. I need to take this medication at least 30 minutes
before the first food or drink of the day
other than water, in an upright position, and
should not lie down for at least 30 minutes after
taking it.
IV. I need to take one tablet every other day.
a.
b.
c.
d.

I and III only


II and III only
II and IV only
I and IV only

64

SECTION I

PHARMACEUTICAL PRACTICE

29. A patient is counseled on the appropriate use of his


new prescription for Betaseron. Which of the
following statements would verify that the patient has
a good understanding of the information that the
pharmacist provided?
I. This medication will help with my Parkinson
symptoms.
II. This medication will help with my depression.
III. I need to tell my doctor if I get fevers or a sore
throat.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

30. Which of the following statements demonstrates that


a female patient understands the risks associated
with cytarabine therapy?
a. I should avoid pregnancy and breast-feeding.
b. I may become constipated while on this
medication.
c. I need to make sure to keep current on my
vaccinations while on this medication.
d. I will have permanent hair loss.
31. A pharmacist has counseled a patient on a new
prescription for the Levemir FlexPen. Which of the
following demonstrates that the patient understands
the storage requirements?
a. I should store the in-use pen with a needle in
place.
b. To avoid injecting myself with cold insulin,
I should keep my pen in a warm place.
c. Once opened, the pen should be stored at room
temperature, but I should keep the rest of the
pens in the refrigerator.
d. Once opened, I should discard the pen after
28 days.
32. Which of the following factors would not be
considered potential barriers to providing a thorough
oral consultation to a patient?
I. Education level
II. Physical impairment
III. Insurance coverage
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

33. Peak flow meters are often classified into three zones.
Which of the following describes this system?
a. Red zone is 80%100%; blue zone is 50%80%;
yellow zone is less than 50%.
b. Green zone is 80%100%; yellow zone is 50%80%;
red zone is less than 50%.
c. Green zone is 50%100%; yellow zone is 30%50%;
red zone is less than 30%.

d.
e.

Red zone is 50%100%; blue zone is 30%50%;


yellow zone is less than 30%.
None of the above

34. Which counseling point(s) should be made regarding


the use of oral ketorolac?
I
It is for short-term use only (up to 5 days).
II. Take with food or milk.
III. Do not break, chew, or crush the tablets.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

35. Which of the following counseling points should be


mentioned to a person wanting to take Xenical?
I. It may cause oily spotting.
II. Take three times daily with each meal containing
fat.
III. Take a multivitamin containing vitamins A, D, E,
and K at the same time as Xenical.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

36. Which of the following counseling points should be


made to the patient taking felodipine (Plendil)?
I. Avoid grapefruit juice while using this
medication.
II. It may cause headache.
III. Take the medication with a high-fat meal.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

37. A patient has a prescription for tranylcypromine


(a MAO inhibitor). Which of the following foods
should the pharmacist advise the patient to avoid?
a. Chianti wine
b. Sauerkraut
c. Aged cheese
d. Pickled fish
e. All of the above
38. A patient with a prescription for simvastatin should
be told which of the following statements?
I. Report any unusual muscle pain or weakness.
II. Avoid large amounts of grapefruit juice.
III. Take the dose first thing in the morning.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

CHAPTER 6

39. A patient has a prescription for Tri-Levlen. Which of


the following counseling points should be made to
the patient?
I. If nausea occurs take with food or at bedtime.
II. Use an additional method of contraception when
taking antibiotics.
III. It may cause weight gain, headaches, and
breakthrough bleeding.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

40. Patients taking ibandronate should be advised to:


I. take it on an empty stomach.
II. swallow tablets whole .
III. lie down for 60 minutes after taking the medication.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

41. A 52-year-old woman complains about menopausal


hot flashes. She wants to avoid using any medication.
She asks the pharmacist if there are any
nonpharmaceutical therapies she can try. What could
the pharmacist suggest?
I. Sip a cold drink if a hot flash is coming on.
II. Exercise regularly.
III. Avoid hot and spicy foods and caffeinated
beverages.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

42. A patient is planning on using a bismuth subsalicylate


preparation. What should the pharmacist tell the
patient?
I. It may discolor stools black.
II. Salicylism is a possible complication with
bismuth subsalicylate if too much is ingested.
III. It may cause severe constipation.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

43. A patient has a prescription for cimetidine for GERD.


Which of the following counseling points should the
pharmacist make to this patient?
a. Elevate the head of the bed.
b. Eat no later than 30 minutes before going to bed.
c. Avoid foods that aggravate symptoms.
d. Avoid smoking.
e. All of the above

Patient Education

65

44. A pharmacist is counseling a new patient in the


anticoagulant clinic who is beginning warfarin
therapy. Which of the following should he avoid?
a. Non-alcoholic wine
b. Vitamin K
c. Vitamin E
d. High-cholesterol foods
e. All of the above
45. Patients taking chlorpropamide should be counseled
to avoid which of the following?
a. Cheese
b. Vitamin K
c. Milk
d. Alcohol
e. Acetaminophen
46. A patient asks a pharmacist for advice on how to quit
smoking and what products to use. Which of the
following statements regarding nicotine replacement
therapy are true?
I. Do not eat or drink 15 minutes before using the
Nicotine lozenge.
II. Nicotine gum works faster than the patch.
III. The patch should not be worn all day; it is used
as a substitute for a cigarette.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

47. A patient asks a pharmacist about the DASH diet. Which


of the following statements about the diet are true?
I. It limits intake of salt, saturated fat and
cholesterol.
II. It emphasizes fruits and vegetables.
III. It includes no red meat.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

48. Which of the following are symptoms of high blood


sugar that should be mentioned when a pharmacist is
counseling a patient with diabetes?
I. Increased thirst
II. Headache
III. Fatigue
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

49. With which of the following medications should a pharmacist counsel the patient to avoid alcohol consumption?
I. Metronidazole
II. Diphenhydramine
III. Warfarin

66

SECTION I

a.
b.
c.
d.
e.

PHARMACEUTICAL PRACTICE

I only
III only
I and III
II and III
I, II, and III

50. A patient goes to the pharmacy counter looking to


purchase Feosol. Which of the following statements
regarding iron supplements is true?
I. It may discolor stool.

II. Taking it with food may increase absorption.


III. Enteric-coated products are preferred over
nonenteric-coated preparations.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

..................................................

Herbs and Dietary Supplements

7
CHAPTER

....................................................................................................................................................................

I.

II.

Complementary and Alternative Medicine (CAM)


and Integrative Medicine
A. CAM is variably defined, but the National Center
for Complementary and Alternative Medicine
(NCCAM) defines CAM as a group of diverse
medical and health care systems, practices, and
products that are not normally considered to
be conventional or allopathic medicine.
B. The Consortium of Academic Health Centers for
Integrative Medicine defines integrative
medicine as the practice of medicine that
reaffirms the importance of the relationship
between practitioner and patient, focuses on
the whole person, is informed by evidence, and
makes use of all appropriate therapeutic
approaches, providers, and disciplines to
achieve optimal health and healing.
C. Why do patients use CAM and integrative
medicine?
1. More active participation in care
2. Perceived safety and lower cost
3. Conventional medicine options are
exhausted
Formulation and Regulation of Dietary Supplements
A. A dietary supplement may include vitamins,
minerals, herbs or other botanicals, amino acids,
and substances such as enzymes, organ tissues,
and metabolites taken in addition to a normal
dietary intake. Supplements are available in many
dosage forms including extracts, concentrates,
tablets, capsules, gel caps, liquids, teas, and
powders. Herbs used for medicinal purposes are
sold in many different forms, including capsules,
tablets, tinctures, teas, powders, whole herbs, and
creams.
1. Examples of dietary supplements
a) Herbals: Gingko, saw palmetto
b) Supplements: Glucosamine, coenzyme Q10
c) Trace minerals: Selenium, chromium, zinc
d) Vitamins: B6, A, C, E, folic acid
e) Hormones: melatonin,
Dehydroepiandrosterone (DHEA)
f) Amino acids: L-tryptophan
2. Decoction: A decoction is the product of boiling
the roots or tough plant material in water to
extract the active principle.
3. Extracts: Pills, powders, liquids, or other forms
of herbs that contain a concentrated and
usually standard amount of therapeutic
ingredients. The most commonly used extracts

are fluid extracts (tinctures), solid extracts,


powdered extracts, and essential oils.
4. Essential oil: Highly volatile, aromatic,
concentrated oil extracted from plants made by
steam distilling volatile compounds from plant
material. Also known as volatile oils, ethereal
oils, or essences, they are usually complex
mixtures of a wide variety of organic
compounds, mostly volatile terpene derivatives
that evaporate when exposed to air.
5. Fluid extracts (tinctures): A concentrated
solution of the soluble constituents of plant
drugs, containing alcohol as both a solvent and
a preservative. Fluid extracts are typically
hydroalcoholic solutions, but they can also
have a glycerin, nonalcoholic base. Alcohol
content varies with each product.
6. Infusion (tea): An herbal product or tea made
by steeping (soaking) herbs in hot water (water
of any temperature) to extract the herbal
qualities. Delicate parts of the plant, like flowers
or leaves, are most often used.
7. Poultices: Topical application of a thick paste of
hot, moist herb or a soft mush, prepared by
wetting powders or other absorbent substances
with oils or water for the purpose of alleviating
pain, reducing inflammation, and promoting
healing.
8. Powdered extracts: Prepared from native
extracts by diluting to the specified strengths
with diluents (e.g., starch, lactose) with or
without anticaking agents (e.g., magnesium
carbonate) followed by drying, usually under
vacuum, to yield dry solids. These are ground
into powders to yield powdered extracts or are
granulated to produce granular extracts.
9. Solid extracts: A highly concentrated herbal
product with a thick syrup-like consistency.
B. Regulation of health claims is largely monitored
by the Dietary Supplement Health and Education
Act (DSHEA), although the Food and Drug
Administration (FDA) and other health alliances
play minor roles.
1. The Dietary Supplement Health and Education
Act (DSHEA) was passed by the US Congress in
October 1994. Topics discussed in DSHEA
include product labeling and content, structure
and function, and health claims. Health claims
describe a relationship between food, food
component, or dietary supplement ingredient,
67

68

SECTION I

PHARMACEUTICAL PRACTICE

Health Claims Approved by the FDA

Table 7-1
Supplement

Health Claim

Calcium
Dietary sugar alcohol (polyols)
Dietary fats
Dietary saturated fat and cholesterol
Fiber-containing grain products, fruits, and vegetables
Folate
Fruits and vegetables
Plant sterol/stanol esters
Potassium
Sodium
Soy protein
Vitamin B3
Vitamin C
Whole grain foods

Reduced risk of Osteoporosis


Does not promote tooth decay
Increased risk of Cancer
Increased risk of coronary heart disease
Reduced risk of coronary heart disease
Prevention of Neural tube defects (in pregnancy)
Reduced risk of Cancer
Reduced risk of coronary heart disease
Reduced risk of high blood pressure and stroke
Increases Hypertension
Reduced risk of coronary heart disease
Treatment of Pellagra
Treatment of Scurvy
Reduced risk of heart disease and certain cancers

or health-related condition, and are not about


treating, mitigating, or curing diseases (Table 7-1).
a) Product labeling: Labels must contain a
descriptive name of the product stating that it
is a supplement; the name and place of
business of the manufacturer, packer, or
distributor; a complete list of ingredients; and
the net contents of the product. Additionally,
each dietary supplement must have nutrition
labeling in the form of a supplement facts
panel and identify each dietary ingredient
contained in the product in order of
abundance in the product (Figure 7-1).

Supplement Facts
Serving Size 1 Capsule
Amount Per
Capsule

% Daily
Value

Calories 20
Calories from Fat 20
Total Fat 2 g
Saturated Fat 0.5 g

3% *
3% *

Polyunsaturated Fat 1 g

Monounsaturated Fat 0.5 g

Vitamin A 4250 IU

85%

Vitamin D 425 IU

106%

Omega-3 fatty acids 0.5 g

* Percent Daily Values are based on a 2,000 calorie diet.


Daily Value not established.
Ingredients: Cod liver oil, gelatin, water, and glycerin.

Figure 7-1Dietary supplement label. Requirements of the label are


found at: http://ods.od.nih.gov/factsheets/dietarysupplements.asp#h6
A ficitious example of a supplement label is available at: http://vm.cfsan.fda.
gov/acrobat/fdsuppla.pdf (Courtesy of U.S. Food and Drug
Administration.)

b) Nutrient content claims: Nutrient content


claims characterize the level of a nutrient in
a food. These types of claims describe the
level of a nutrient or dietary substance in
the product using terms like free, high, and
low, or they compare the level of a nutrient
in a food to that of another food using terms
such as more, reduced, and light. For
example, a product containing 500 mg of
calcium may claim high in calcium.
c) If a dietary supplement label includes such a
claim, this following statement must appear
on labels: THESE STATEMENTS HAVE NOT
BEEN EVALUATED BY THE FDA. THIS
PRODUCT IS NOT INTENDED TO DIAGNOSE,
TREAT, CURE OR PREVENT ANY DISEASE.
The content of the label must be provided to
the FDA 30 days before labeling.
d) Structure and function claims explain the
role of a nutrient or dietary ingredient
intended to affect normal structure or
function in humans, for example, calcium
builds strong bones or fiber maintains
bowel regularity. Structure and function
claims may also describe a benefit related to
a nutrient deficiency disease (e.g., vitamin C
and scurvy), as long as the statement also
tells how widespread such a disease is in the
United States. The manufacturer is
responsible for ensuring the accuracy and
truthfulness of these claims; they are not
preapproved by the FDA, but they must be
truthful and not misleading.
2. The FDA has a limited role in regulating the
quality of individual products.
a) The 1990 Nutrition Labeling and Education
Act (NLEA) provides for the FDA to issue
regulations authorizing health claims for
foods and dietary supplements after the
FDAs careful review of the scientific
evidence submitted in health claim petitions.

CHAPTER 7

b) The 1997 Food and Drug Administration


Modernization Act (FDAMA) provides for
health claims based on an authoritative
statement of a scientific body of the United
States government or the National Academy
of Sciences; such claims may be used after
submission of a health claim notification to
FDA.
c) The 2003 FDA Consumer Health Information
for Better Nutrition Initiative provides for
qualified health claims for which the quality
and strength of the scientific evidence falls
below that required for FDA to issue an
authorizing regulation. Such health claims
must be qualified to ensure accuracy of
presentation to consumers.
3. In the United States, the FDA does not function
to guarantee the strength, purity, or safety of
dietary supplements. Companies are expected
to prove the efficacy and safety of their
products.
a) The Office of Dietary Supplements (ODS) at
the National Institutes of Health (NIH) was
designed to strengthen knowledge and
understanding of dietary supplements
by evaluating scientific information,
stimulating and supporting research,
disseminating research results, and
educating the public to foster an enhanced
quality of life and health for the United
States population.
b) The United States Department of Agriculture
(USDA) provides leadership on food,
agriculture, natural resources, and related
issues based on sound public policy, the
best available science, and efficient
management. The USDA developed a Dietary
Supplement Ingredient Database, which

Table 7-2

Herbs and Dietary Supplements

69

monitors the levels of ingredients in dietary


supplement products.
4. Third party testing: Independent laboratories
that test products to ensure that the label
matches the product include Consumer Lab,
Consumer Reports, Natural Products
Association, NSF International, and the United
States Pharmacopeia (USP). Quantitative and
qualitative testing often finds that brand-tobrand and batch-to-batch variation exists in
products.
III. Common uses, adverse effects, and potential
interactions of popular herbs and supplements, as
well as manual therapies
A. Clinicians are encouraged to recommend doses of
herbs and supplements based on those most
commonly used in human trials and clinical
experience. However, with natural products it is
often not clear what the optimal doses are to
balance effectiveness and safety due to a lack of
scientific data and the lack of standardization.
B. Why is this knowledge important for patient
counseling?
1. Many patients do not reveal their use of herbal
remedies because they are in fear of being
judged or criticized.
2. Clinicians can provide information about
recommended doses, frequencies, and specific
brand-name products used in clinical trials.
C. Table 7-2 summarizes common herbs and
supplements used in the United States, adverse
effects, and potential interactions based on
mechanism of action and laboratory, animal, or
human evidence.
D. Manual therapies are also part of integrative
medicine, and are often financially covered under
health insurance plans. The risks of side effects
should be noted (Table 7-3).

Top Herbs and Supplements in the United States

Common Name

Common Uses

Barley

Coronary heart
disease

Coenzyme
Q10
(Co Q-10)

CoQ-10 deficiency,
heart disease,
antioxidant, high
blood pressure

Special Considerations, Adverse


Effects
Use cautiously with
diabetes, asthma, or
arrhythmia
May reduce blood pressure;
may reduce blood sugar

Possible Interactions
Oral agents, cholesterol-lowering drugs, and
herbs or supplements with similar effects
Alzheimer drugs, anticoagulants/
antiplatelets, antiretrovirals, antivirals,
beta blockers, cancer drugs, clonidine,
methyldopa, hydralazine,
antidepressants, antipsychotics, blood
pressure drugs, blood sugar medications,
cholesterol-lowering drugs (statins),
some diuretics, heart drugs, immune
system-altering drugs, ginkgo, garlic,
horsetail, red yeast, vitamin E, vitamin K,
and other herbs or supplements with
similar effects
Continued

70

SECTION I

Table 7-2

PHARMACEUTICAL PRACTICE

Top Herbs and Supplements in the United Statescontd

Common Name

Common Uses

Special Considerations, Adverse


Effects

Echinacea

Common cold,
influenza,
respiratory
infections,
immune system
stimulant

May cause allergic reactions;


to be avoided if allergic to
plants in the daisy family
including ragweed,
chrysanthemums, and
marigolds

Garlic

Cardiovascular
disease (high
cholesterol, high
blood pressure)

Ginkgo biloba

Improve memory,
prevent
dementia,
Alzheimer
disease,
cognitive
function

May cause bad breath, body


odor, and allergic
reactions; may increase
the risk of bleeding; avoid
use with anticoagulants/
antiplatelets; may lower
blood sugar levels
May cause headache,
nausea, gastrointestinal
upset, diarrhea, and
dizziness; may increase
bleeding risk

Ginseng

Diabetes, energy
enhancement,
erectile
dysfunction

May cause headaches as


well as sleep and
gastrointestinal
problems; may lower
blood sugar

Glucosamine/
chondroitin

Osteoarthritis

May increase intestinal gas


and soften stool; patients
with diabetes should
monitor glucose; may
increase anticoagulant
effects of warfarin

Possible Interactions
Amoxicillin, anesthetics, antineoplastic
agents, caffeine, corticosteroids,
cytochrome P450 metabolized agents,
disulfiram (Antabuse), econazole nitrate
(Spectazole), hydrophilic agents,
immunosuppressants, liver-damaging
agents, metronidazole (Flagyl),
and herbs and supplements with similar
effects
Drugs that increase bleeding,
anticoagulants/antiplatelets,
antihypertensives, cholesterol-lowering
drugs, thyroid drugs, human growth
hormone, vitamin E, fish oils, and herbs
or supplements with similar effects
Antidepressants, antipsychotic drugs, drugs
that increase risk of bleeding, drugs used
for erectile dysfunction (e.g., Viagra),
blood pressure drugs, drugs that alter
blood sugar levels, drugs metabolized by
the liver, seizure drugs, aged foods (wine
and cheese), St. Johns wort, garlic, bitter
melon, and herbs or supplements with
similar effects
Anticoagulants/blood thinners, drugs that
are broken down by the liver, HIV drugs
such as protease inhibitors, drugs that
lower blood sugar levels, digoxin
(Lanoxin), nifedipine (Procardia), blood
pressure drugs, over-the-counter drugs
for treating cold symptoms (e.g.,
pseudoephedrine), diuretics, central
nervous system stimulants such as
methylphenidate (Ritalin),
corticosteroids, hormonal drugs,
antipsychotics, opioids such as
morphine, phenelzine (Nardil), alcohol,
metronidazole (Flagyl), disulfiram
(Antabuse), and herbs or supplements
with similar effects
Drugs that alter blood sugar levels, diuretics,
drugs that increase the risk of bleeding
such as aspirin, anticoagulants/antiplatelet drugs, NSAID, herbs or
supplements with similar effects (e.g.,
arginine, cocoa, ephedra, juniper berry,
kava, shepherds purse, sweet clover,
turmeric, vitamin E)

CHAPTER 7

Table 7-2

Herbs and Dietary Supplements

71

Top Herbs and Supplements in the United Statescontd

Common Name

Common Uses

Special Considerations, Adverse


Effects

Kava

Anxiety

May cause liver damage

Melatonin

Sleep disorders

May cause daytime


drowsiness, dizziness,
gastrointestinal cramps
and headache; may cause
additive sedation when
used with CNS
depressants

Saw palmetto

Benign prostatic
hyperplasia
(BPH)

May increase risk of


bleeding

Soy

Menopause, breast
cancer,
osteoporosis

May cause gastrointestinal


upset; may have
estrogenic effects

Possible Interactions
ACE inhibitors, alcohol, antianxiety drugs,
anticoagulants/antiplatelets,
antidepressant agents, antineoplastic
agents, anxiety medications, CNS
depressants, contraceptives, cytochrome
P450 metabolized agents, diuretics,
dopamine agonists, dopamine
antagonists, drugs eliminated by the
kidneys, gastrointestinal agents,
hepatotoxic (liver-damaging) agents,
hormonal agents, mood stabilizers,
neurologic agents, pain relievers, painnumbing agents, sedatives, tranquilizers,
and herbs and supplements with similar
effects
Drugs broken down by the liver, sedative
drugs (e.g., Ambien), barbiturates,
narcotics, antidepressants, alcohol, drugs
that increase the risk of bleeding such
as warfarin (Coumadin), anticoagulants
(e.g., aspirin or heparin), nonsteroidal
antiinflammatories (e.g., ibuprofen),
naproxen (Naprosyn, Aleve), drugs that
affect blood pressure (e.g., atenolol),
drugs that lower levels of vitamin B6 in
the body (e.g., birth control pills,
hormone replacement therapy, or loop
diuretics), diazepam, verapamil,
temazepam, somatostatin, drugs that
alter blood sugar levels (e.g., insulin),
caffeine, succinylcholine,
methamphetamine, isoniazid, herbs or
supplements with similar effects (e.g.,
5-HTP, ginkgo biloba, garlic, saw
palmetto, vitamin B12, chasteberry,
arginine, DHEA, echinacea)
Androgenic drugs, antiandrogenic drugs,
antibiotics, antiinflammatory agents,
antineoplastic agents, blood pressure
altering agents, blood thinning agents,
disulfiram (Antabuse), drugs that may
lower seizure threshold, hormonal agents,
immunomodulators, and herbs and
supplements with similar effects
Birth control pills containing estrogen,
selective estrogen receptor modulators
(e.g., tamoxifen), aromatase inhibitors
(e.g., anastrozole [Arimidex], exemestane
[Aromasin], or letrozole [Femara]), bloodthinning drugs (e.g., warfarin), calcium,
iron, phosphate, panax ginseng, and
herbs and supplements with similar
effects
Continued

72

SECTION I

Table 7-2

PHARMACEUTICAL PRACTICE

Top Herbs and Supplements in the United Statescontd


Special Considerations, Adverse
Effects

Common Name

Common Uses

St. Johns wort

Depression (mild to
moderate)

May increase sensitivity to


sunlight; may cause
headache, sexual
dysfunction, and
dizziness; induces
CYP450 2C9 and 3A4;
increases risk of
serotonin syndrome
when used with certain
antidepressants or other
drugs increasing
serotonin levels

Fish oil/
omega-3
fatty acids

Cardiovascular
disease (high
blood pressure,
high
cholesterol),
rheumatoid
arthritis

May cause gastrointestinal


upset; may increase
bleeding; may increase
blood sugar

Milk thistle

Liver disease, liver


protection

May cause gastrointestinal


upset; may lower blood
sugar levels

Possible Interactions
Drugs that are broken down by the liver
such as birth control pills, warfarin,
cyclosporine, carbamazepine, digoxin,
antidepressants, antibiotics, loperamide
(Imodium), migraine drugs, irinotecan
(CPT-11), HIV drugs such as
nonnucleoside reverse transcriptase
inhibitors or protease inhibitors,
theophylline, drugs that affect thyroid
activity, antiinflammatories, 5-HT1
receptor agonists (triptans), alcohol,
anesthetic drugs, antifungals,
antineoplastic drugs, benzodiazepine,
calcium channel blocking drugs
(verapamil), dextromethorphan,
histamine H1 antagonist (MDRI), HMG CoA
reductase inhibitors (statins), imatinab
(Gleevac), irinotecan (CPT-11,
Camptosar), loperamide (Imodium),
methadone, monoamine oxidase
inhibitors (MAOI), mycophenolic acid,
nifedipine (e.g., Procardia, Adalat),
P-glycoproteinregulated drugs, drugs
that increase sun sensitivity, omeprazole,
selective serotonin reuptake inhibitors
(SSRI), tacrolimus (Prograf), theophylline,
drugs for thyroid disorders, cardiac
glycoside herbs and supplements, iron,
red yeast rice, valerian, foods containing
tyramine/tryptophan (e.g., cheese, wine,
yogurt, caffeine, soy sauce, and
chocolate), and herbs and supplements
with similar effects (e.g., hops, oleander,
fenugreek)
Drugs that increase the risk of bleeding
(anticoagulants) such as warfarin or
heparin, antiplatelet drugs,
antiinflammatories such as ibuprofen
(Motrin, Advil), drugs that lower blood
pressure, drugs that may alter blood
sugar levels (e.g., insulin), drugs that
lower cholesterol such as atorvastatin
(Lipitor), vitamins A, E and D, and other
herbs and supplements with similar
effects
Drugs broken down by the liver, drugs used
to control blood sugar levels, phenytoin
(Dilantin), cancer drugs (doxorubicin,
cisplatin, and carboplatin), and herbs or
supplements with similar effects (e.g.,
aloe vera, American ginseng, bilberry,
bitter melon, burdock, fenugreek, fish oil,
gymnema, horse chestnut/horse chestnut
seed extract, marshmallow, milk thistle,
panax ginseng, rosemary, Siberian
ginseng, stinging nettle, vitamin E)

CHAPTER 7

Table 7-2

Herbs and Dietary Supplements

73

Top Herbs and Supplements in the United Statescontd

Common Name

Common Uses

Special Considerations, Adverse


Effects

Black cohosh

Menopause

May cause liver damage

Ginger

Nausea

May increase the risk of


bleeding

Calcium

Antacid, bone loss


prevention,
osteoporosis

May cause kidney stones in


high doses; to be avoided
with hypercalcaemia,
hypercalciuria,
hyperparathyroidism,
bone tumors, digitalis
toxicity, ventricular
fibrillation, or sarcoidosis

Vitamin D

Rickets,
osteoporosis

Use cautiously with


hyperparathyroidism
(overactive thyroid),
kidney disease,
sarcoidosis, tuberculosis,
and histoplasmosis

Possible Interactions
Alcohol, anesthetics, antiestrogen drugs
(e.g., Tamoxifen), antiseizure drugs,
aspirin or nonsteroidal
antiinflammatories/pain relievers, blood
pressure drugs, drugs broken down by the
liver, cholesterol-lowering drugs, drugs for
depression (MAOI or SSRI),drugs for
seizures, drugs (e.g., raloxifene), drugs
that increase the risk of bleeding (e.g.,
warfarin [Coumadin]), estrogens (e.g.,
hormone replacement therapy drugs, birth
control pills), and herbs and supplements
with similar effects
Antacids, antiinflammatory agents,
antiarrhythmic agents, antiarthritic
agents, antidiabetic agents, antiemetics,
antihistamines, antineoplastic agents,
antiobesity agents, antitussives, beta
blockers, blood pressure medications,
blood thinners, cardiac glycosides,
cardiovascular agents, cholesterol
medications, CNS depressants,
cytochrome P450 metabolized agents,
xanthine oxidase, dexamethasone,
gastrointestinal agents, H2 blockers,
immunosuppressants, nifedipine,
nonsteroidal antiinflammatory agents,
COX 2 inhibitors, P-glycoprotein
regulated drugs, proton pump inhibitors,
sedatives, vasodilators, warfarin, and
herbs and supplements with similar
effects
Alcohol, aluminum-containing compounds,
antacids, anticonvulsants,
anti-inflammatories, antibiotics,
bisphosphonates, blood pressure
medications, caffeine, calcium channel
blockers, cholesterol medications,
corticosteroids, diuretics, estrogen, heart
medications, hormone replacement
therapy, levothyroxine, mineral oil,
orlistat (Xenical, Alli), phosphorus,
potassium, proton pump inhibitors,
stimulant laxatives, tetracycline, vitamin
D, and herbs and supplements with
similar effects
Antiseizure drugs, calcium, cholestyramine
or colestipol, corticosteroids, digoxin,
magnesium-containing antacids, mineral
oil, orlistat (an obesity drug), rifampin,
stimulant laxatives, thiazide diuretics
including chlorothiazide (Diuril),
chlorthalidone (Hygroton, Thalitone),
hydrochlorothiazide (HCTZ, Esidrix,
HydroDIURIL, Ortec, Microzide),
indapamide (Lozol), and metolazone
(Zaroxolyn), and herbs and supplements
with similar effects
Continued

74

SECTION I

Table 7-2

PHARMACEUTICAL PRACTICE

Top Herbs and Supplements in the United Statescontd

Common Name

Common Uses

Vitamin E

Vitamin E deficiency

Special Considerations, Adverse


Effects

Possible Interactions

May cause abdominal pain/


GI upset, blurred vision/
dizziness (particularly
when used in high doses),
diminished kidney
function, increased rate
of hemorrhagic
(bleeding) stroke and
gum bleeding, increased
risk of bleeding, and
weakness

Anticoagulants, anticonvulsants,
antioxidants, antiplatelet drugs, bloodthinning drugs, chemotherapy agents,
cholesterol-lowering medications,
cholestyramine (Questran), colestipol
(Colestid), orlistat (Xenical, Alli),
isoniazid (INH, Lanizid, Nydrazid), olestra
(Olean fat substitute), and sucralfate
(Carafate), cyclosporine, gemfibrozil
(Lopid), nonsteroidal antiinflammatory
drugs such as ibuprofen (Motrin, Advil)
or naproxen (Naprosyn, Aleve), and herbs
and supplements with similar effects

From Natural Standard, www.naturalstandard.com, #2008.

Table 7-3

Manual Therapies and Adverse Effects

Manual Therapy

Special Considerations, Adverse Effects

Acupuncture

Needles must be sterile to avoid disease transmission. Avoid with valvular heart disease,
infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants),
medical conditions of unknown origin, neurological disorders. Avoid on areas that have
received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g.,
asthma or emphysema). Use cautiously in elderly or medically compromised patients and in
those with diabetes or with history of seizures. Avoid electroacupuncture with arrhythmia
(irregular heartbeat) or in patients with pacemakers.
Forceful acupressure may cause bruising.
Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that
cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding
disorders, or migraines. Use cautiously with the risk of tumors or cancers. Avoid with symptoms of
vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis or arthritis. Avoid
with agents that increase the risk of bleeding. Avoid in areas of paraspinal tissue after surgery.
Avoid some inverted poses with disc disease of the spine, fragile, or atherosclerotic neck arteries,
risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina,
ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques
should be avoided by people with heart or lung disease.

Acupressure
Chiropractic
(manual
adjustments)

Yoga

Examples of Resources for the Clinician


Natural Standard: www.naturalstandard.com.
National Center for Complementary and Alternative
Medicine: www.nccam.nih.gov.
Consumer Lab: www.consumerlab.com.

REVIEW QUESTIONS
(Answers and Rationales on page 335.)
1. Which of the following statements about DSHEA is
true?
a. It defines dietary supplements and dietary
ingredients.
b. It provides for use of claims and nutritional
support statements.

c.
d.
e.

It requires ingredient and nutrition labeling.


It establishes good manufacturing practice
(GMP) regulations.
All of the above

2. Which of the following statements about kava is true?


I. It may cause nephrotoxicity.
II. It may be used to increase cognition.
III. Alcohol consumption increases
toxicity.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

CHAPTER 7

3. Which is NOT an example of a government resource


on CAM?
a. NCCAM
b. ODS
c. CFSAN
d. ASHP Essentials
4. Which of the following is popularly used to stimulate
the immune system?
a. Valerian
b. Chamomile
c. Chasteberry
d. Echinacea
e. Kava
5. A patient with poison ivy asks the pharmacist if she
can use a skin lotion that contains comfrey.
What should the pharmacist tell the patient?
a. Comfrey-containing products are not recommended for use in any form due to possible toxicity.
b. Comfrey-containing lotions should help to dry
weeping lesions.
c. An oral comfrey supplement will be more
effective.
d. Apply comfrey-containing products to the open
lesions.
6. Which of the following are considered fat-soluble
vitamins?
a. Vitamin K
b. Vitamin A
c. Vitamin D
d. Vitamin E
e. All of the above
7. Licorice is commonly used for which of the following?
a. Peptic ulcers
b. Depression
c. Benign Prostatic Hypertrophy (BPH)
d. Osteoarthritis
e. Diabetes
8. Which of the following has been shown to interact
with medications by inhibition of cytochrome P450
3A4 in the intestinal wall?
a. Kava
b. Ginkgo
c. Grapefruit
d. St. Johns wort
9. The mechanism of grapefruits interaction with
medications is through:
a. induction of CYP 3A4.
b. inhibition of CYP 3A4.
c. induction of CYP 2D6.
d. inhibition of CYP 2D6.
10. Saw palmetto is commonly taken to improve:
a. vasomotor symptoms associated with menopause.
b. sleep patterns in shift workers.
c. urinary symptoms associated with Benign
Prostatic Hypertrophy (BPH).
d. mental alertness.

Herbs and Dietary Supplements

75

11. There is good evidence to suggest that which of the


following is effective in treating Benign Prostatic
Hyperplasia (BPH)?
a. Yohimbine
b. Valerian
c. Horsetail
d. Saw palmetto
12. Which of the following statements about black
cohosh is true?
I. It may cause hepatotoxicity.
II. It is popularly used for menopausal hot
flashes.
III. It is a strong CYP450 2C9 inducer.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

13. Which of the following statements about yohimbine


is true?
a. Yohimbine is used to treat impotence although
there is not enough scientific evidence to form a
firm conclusion in this area.
b. Yohimbine is used as a stimulant to increase
cognition.
c. Yohimbine is a MAO inhibitor and should be
avoided with foods containing tyramine.
d. a and c
e. None of the above
14. What are compounds produced by plants for their
protection?
a. Botanochemicals
b. Phytochemicals
c. Phytomedicinals
d. Aetheroleum
15. Which of the following are examples of
phytochemicals?
A. Flavonoids
B. Phytoestrogens
C. Tannins
D. All of the above
16. What phytochemicals have estrogenic activity?
a. Antiandrogens
b. Isoestrogens
c. Benzylic estrogens
d. Phytoestrogens
17. Which of the following may be used to decrease
homocysteine levels?
I. Vitamin B6
II. Vitamin B12
III. Folic acid
a.
b.
c.
d.
e.

I only
III only
I and II
I and III
I, II, and III

76

SECTION I

PHARMACEUTICAL PRACTICE

18. What is the mechanism by which glucosamine and


chondroitin are suggested to treat osteoarthritis?
a. Immunomodulatory
b. Anti-inflammatory
c. Analgesic
d. Production and maintenance of healthy cartilage
19. True or False: Calcium carbonate should be taken
with meals to enhance absorption.
a. True
b. False
20. Patients with which of the following food allergies
should use caution when choosing glucosamine
supplements?
a. Peanut
b. Tree nuts
c. Dairy
d. Shellfish
21. Hypericum perforatum is also known as:
a. bitter orange
b. hydrangea
c. St. Johns wort
d. hyoscine
22. What cytochrome P450 enzyme is primarily induced
by St. Johns wort?
a. 2C8
b. 2C9
c. 2D6
d. 3A4
23. Pyridoxine may interact with which of the following?
I. Isoniazid
II. Oral contraceptives
III. Levodopa
a.
b.
c.
d.
e.

I only
III only
I and II
I and III
I, II, and III

24. Which of the following herbs/supplements is used for


erectile dysfunction?
a. Saw palmetto
b. Yohimbine
c. Kava
d. Black cohosh
e. None of the above

27. Which of the following herbs is used to increase milk


supply in breastfeeding women?
a. Fenugreek
b. Yarrow
c. Cascara sagrada
d. Garlic
e. None of the above
28. Patients with which of the following conditions may
be thiamine deficient?
I. Alcoholism
II. Chronic diarrhea
III. Korsakoff psychosis
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

29. Which of the following statements is FALSE?


a. DSHEA places dietary supplements under the
category of food, not drugs.
b. Third-party testers like Consumer Lab test the
chemical ingredients of products.
c. Each dietary supplement must have nutrition
labeling with the panel title Nutritional Facts
like other products sold on store shelves.
d. It is required that every supplement be labeled
a dietary supplement.
30. What is a common herb used in sleep remedies?
a. Kava
b. Hypericum
c. Valerian
d. Ginkgo
e. Ginseng
31. The mechanism by which cranberries prevent urinary
tract infections (UTI) is thought to be:
I. inhibition of bacterial adherence to uroepithelial
cells.
II. acidifying the urine.
III. restoring the urogenital flora.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

25. Garlic use has been reported to cause:


a. bleeding
b. muscle pain
c. blurred vision
d. increased blood pressure
e. None of the above

32. Which of the following herbs is used to stimulate the


immune system?
a. Echinacea
b. Ginseng
c. Melatonin
d. Saw palmetto
e. All of the above

26. True or False: The DSHEA is an organization that


regulates good manufacturing practice for dietary
supplements.
a. True
b. False

33. The use of which of the following herbs has been


reported to cause liver damage?
a. Kava
b. Black cohosh
c. Saw palmetto

CHAPTER 7

d.
e.

Hypericum perforatum
Both a and b

34. Which of the following is commonly used to support


mental energy?
a. Ginseng
b. Melatonin
c. Echinacea
d. Grapefruit
e. Garlic
35. Which of the following is a common side effect of
St. Johns wort?
a. Photosensitivity
b. Diarrhea
c. Breath odor
d. Heartburn
e. Hepatotoxicity
36. For
a.
b.
c.
d.
e.

what may feverfew be used?


Diabetes
Common cold
Migraine prevention
Depression
None of the above

37. All of the following statements are true about the


Dietary Supplement Health and Education Act of 1994
(DSHEA) EXCEPT:
a. Dietary supplements must undergo FDA approval
after clinical studies to determine effectiveness
and safety.
b. The manufacturer is responsible for safety
evaluation.
c. Authorized use of FDA approved health claims on
label.
d. Products must be labelled as Dietary
Supplements.
38. Which of the following is considered a mineral
supplement?
I. Biotin
II. Choline
III. Calcium
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

39. Which of the following products contains


calcium?
I. Tums EX
II. VIACTIV
III. Os-Cal
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

Herbs and Dietary Supplements

77

40. True or False: Ferrous salts are more efficiently


absorbed than ferric salts.
a. True
b. False
41. Which of the following products does NOT contain
vitamin K?
I. Centrum
II. Centrum Silver
III. Unicap Senior Multivitamin
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

42. Topical capsicum may be used for which of the


following?
a. Neuropathic pain
b. Shingles
c. Osteoarthritis
d. All of the above
43. Which of the following statements about ephedra is
true?
I. It is used for weight loss.
II. It may interact with MAOI.
III. It was removed from the market by the FDA due
to safety concerns.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

44. True or False: Iodine is used to synthesize thyroxine


(T4) and triiodothyronine (T3).
a. True
b. False
45. Chasteberry is commonly used for:
a. Premenstrual syndrome (PMS)
b. blood pressure
c. tinnitus
d. migraine
e. None of the above
46. Which of the following herbs will likely cause
drowsiness?
a. Yohimbine
b. Valerian
c. Ma huang
d. Guarana
e. Kola nut
47. Which of the following herbs is commonly found in teas?
a. Garlic
b. Ginkgo
c. Capsicum
d. Chamomile
e. None of the above

78

SECTION I

PHARMACEUTICAL PRACTICE

48. Which of the following common cold products


contain(s) zinc?
I. Airborne
II. Zicam
III. Cold-eeze
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

49. Which of the following may cause discoloration of


skin or urine?
a. Pyridoxine
b. Riboflavin
c. Thiamine
d. Cyanocobalamin
e. None of the above

..................................................

Laboratory Tests

CHAPTER

....................................................................................................................................................................

I. Introduction
Laboratory tests are an essential tool in clinical medicine.
They are used to help identify, diagnose, or confirm a
disease or health problem. They are also used for
differential diagnosis, to stage disease, and to monitor
disease progression or responsiveness to a given
treatment. Laboratory testing is most beneficial when the
test influences a course of treatment or decision making
with regard to a patients health.
A. Laboratory tests are of two main types:
1. Screening tests: used in patients with no active
symptoms or signs of a health problem or
disease, usually for purposes of early detection
or mitigation of health risk factors for serious
disease.
2. Diagnostic tests: used to analyze an abnormal
screening test or to establish additional
information in patients with signs and
symptoms of a health problem or
disease.
B. It is important for the pharmacist to have a strong
knowledge of the more common laboratory tests
used to guide patient diagnosis and treatment.
Pharmacists are likely to review laboratory tests to
assess the efficacy and the safety of medications.
They may recommend testing when necessary or
may be called to help interpret the results obtained
from such tests. A pharmacist may be asked to help
a patient understand the results of a particular test.
II. The International System of Units (SI), Conventional
Units of Measure, and the Reporting of Laboratory
Results
A. Around the world, laboratory tests are reported in
the SI units, which are based on standard metric
measurements. The United States has yet to fully
adopt this system, and laboratories typically
report results in traditional, customary units as
well as the SI units. The reporting of both types of
units typically aids communication among health
care professionals of different training
backgrounds or nationalities.

B. Normal laboratory results usually fall within a


reference range of values determined by taking
the usual measurements of that test found within a
set and defined population of healthy individuals.
For qualitative tests, results are often reported as
either positive or negative for a specific finding.
Quantitative tests are usually reported in terms of
a reference range. For most tests, the reference
range is statistically determined by the mean value
plus two standard deviations. Values that fall out
of the reference range or expected result are
sometimes labeled abnormal. A value that falls
outside an accepted range does not necessarily
indicate the need for treatment or a need to make
the value normal. An abnormal result requires
interpretation in the context of the patients
demographics, overall health status, medical
examination findings, symptoms, timing and
conditions of the test, and other relevant factors.
A test may not produce results consistent with
the results expected, and a repeat test may be
needed to rule out errors in collection or
processing of the test.
III. The Most Common Laboratory Tests Pharmacists
Should Know (Tables 8-1 through 8-6)
A. The following sections will provide a brief synopsis
and review of laboratory testing familiar to the
pharmacist, including the common medical
reasons the tests are monitored. The lists are not
inclusive, but are representative of the tests
pharmacists are most likely to encounter in their
general clinical practices.
B. For greater details regarding how the test is used,
please refer to the specific therapeutic chapter in
this review. For example, a more complete
discussion of the use of HbA1c for the
monitoring of diabetes mellitus would be
found in the chapter discussing diabetes
treatments.
C. Ranges are given in conventional reporting units in
the United States.

79

80

SECTION I

Table 8-1

PHARMACEUTICAL PRACTICE

Electrolytes and Minerals/Acid Base; Common Serum Enzymes

Substance

Reference Range
(Typical Adult Range)

Sodium

135146 mEq/L

Potassium

3.55.3 mEq/L

Chloride

98110 mEq/L

Bicarbonate (venous)
Magnesium

2233 mEq/L
1.62.6 mg/dL

Calcium

8.610.2 mg/dL

Phosphorous

2.44.4 mg/dL

Uric acid

2.66 mg/dL

Low-density
lipoprotein (LDL)
cholesterol
High-density
lipoprotein (HDL)
cholesterol
Total cholesterol

<130 mg/dL

Alkaline phosphatase
(ALP)

33115 units/L

Produced by liver and bones

Creatinine kinase
(CK)

20200 units/L

Lactate
dehydrogenase
(LDH)

100200 units/L

Isoenzymes of CK found
primarily in heart, brain, and
skeletal muscle; elevations
indicate tissue damage
Isoenzymes found primarily in
heart, lungs, liver, and skeletal
muscle

Comments

Commonly Used to Detect

<100 is better for many adults to


reduce heart disease risk

Hypo- or hypernatremia, aid in


determining osmolality
Hypo- or hyperkalemia; monitoring
renal function; effects of
medications
Acid-base balance (e.g., from
vomiting, diarrhea)
Acid-base balance
Hypo- or hypermagnesemia;
hypomagnesemia is more
common
Hypo- or hypercalcemia; renal
osteodystrophy; metastatic
malignancy; parathyroid
hormone (PTH) abnormalities
Hypo- or hyperphosphatemia;
renal insufficiency
Gout or hyperuricemia due to
medications (e.g., cytolytic
chemotherapies)
Hypercholesterolemia and heart
disease risk

46 mg/dL

Hypercholesterolemia and heart


disease risk

<200 mg/dL

Hypercholesterolemia and heart


disease risk
Increase in osteoblastic activity
(e.g., Paget disease); biliary
obstruction
Acute myocardial infarction

Pattern of elevations to help in


diagnosis of myocardial
infarction, liver or lung disease

CHAPTER 8

Table 8-2

81

Renal Tests
Reference Range
(Typical Adult Range)

Test
Serum
creatinine
(SCr)

0.51.2 mg/dL

Blood urea
nitrogen
(BUN)

625 mg/dL

Creatinine
clearance
(CrCl)

59137 mL/min/
1.73 m2

BUN:SCr ratio

622

Modified diet in
renal disease
(MDRD)
estimation of
GFR

60 mL/min/
1.73 m2

Table 8-3

Laboratory Tests

Comments

Commonly Used To Detect

Decreased muscle mass in elderly


may give low result and may be
misleading; creatitine clearance
(CrCl) should be calculated or
estimated to more reliably
estimate renal function

Elevated in renal impairment,


indicating decreased glomerular
filtration rate (GFR)

Estimates GFR
Can be measured formally by 24-hour
urine collection; most commonly
calculated using Cockroft-Gault
method to estimate, using SCr, ideal
body weight, and age; renal dosing
of medications is primarily based
on adjustments according to CrCl

Another way to validate GFR; has not


been used to determine drug
dosing

Decreased when liver disease is


significant; increased with
dehydration, overdiuresis,
decreased renal function, protein
intake
Lowered CrCL indicates a decline in
renal function

When elevated, commonly indicates


dehydration or overdiuresis
Used to determine staging of renal
disease; the calculation is now
commonly reported as part of a
laboratory panel

Urinalysis

Test

Reference Range
(Typical Adult Range)

Appearance or
color

Clear, yellow (pale to


gold)

pH

4.58

Specific gravity

1.0021.030

Comments

Indicates solute particles in


urine

Commonly Used To Detect


Dark brown color may indicate
excretion of bilirubin; other
colors (e.g., red) may indicate
blood or drug effect
Alkaline pH may indicate alkalosis,
use of carbonic anhydrase
inhibitor, or infection by certain
bacteria (e.g., Proteus sp)
Increased with diabetes mellitus or
nephrosis; decreased with
diabetes insipidus; may indicate
loss of kidneys ability to dilute
or concentrate urine
Continued

82

SECTION I

Table 8-3

PHARMACEUTICAL PRACTICE

Urinalysiscontd

Test

Reference Range
(Typical Adult Range)

Protein

114 mg/dL

Glucose

Negative

Ketones

Negative

Microscopic
evaluation

Negative to very few


WBC or RBC, no
crystals and only an
occasional cast, no
to few bacteria

Table 8-4

Comments

Commonly Used To Detect

Most proteins do NOT filter if


the person is healthy

Proteinuria may indicate renal


disease or diabetic
nephropathy; urinary tract
infection; specific proteins may
indicate certain diseases.
Albuminuria may indicate
abnormal glomerular function
Positive result occurs most
commonly in diabetes mellitus
Positive result occurs most
commonly in uncontrolled
diabetes mellitus; may also
occur with starvation or lowcarbohydrate diets
Presence of specific elements
indicates infection, trauma,
kidney stones, etc.

Looks for crystals, red blood


cells, protein casts from
renal tubules, bacteria;
urine collection, if not done
properly, can contaminate
the sample

Hepatic Tests

Substance

Reference
Range (Typical
Adult Range)

Comments

Aspartate
aminotransferase
(AST)

1030 units/L

Alanine
aminotransferase
(ALT)
Albumin

640 units/L

Total serum protein


Serum bilirubin (total
bilirubin)

6.28.3 g/dL
0.21.2 mg/dL

Direct bilirubin

<0.2 mg/dL

Conjugated form of bilirubin

Ammonia

1080 mcg/dL

A by-product of protein
metabolism that is removed
by the liver

3.65.1 g/dL

Commonly Used To Detect


Elevated in acute hepatitis; milder
elevations in cirrhosis, fatty liver,
or acute congestion caused by
heart failure
Elevated in liver dysfunction,
hepatitis, cirrhosis, etc.

Decreased production in liver


disease; important as a
transport agent; maintains
osmotic pressure
Measures albumin plus globulins
Clinical result of increased
bilirubin is jaundice

Nutritional status; liver function;


useful in therapeutic drug
monitoring (e.g., phenytoin
monitoring)
Nutritional status and liver function
Without an associated increase in
direct bilirubin, elevation may
indicate hemolysis; also increased
with biliary obstruction or liver
disease
Elevated in biliary obstruction or
liver necrosis
Elevated in hepatic encephalopathy/
hepatic failure

CHAPTER 8

Table 8-5

83

Laboratory Tests

Hematologic Tests

Substance

Reference Range
(Typical Adult Range)

Comments

3.55.9 million/mm3

Red blood cell (RBC)


count
Hemoglobin (Hb)

1218 g/dL

Hematocrit (Hct)

37%52%

Mean corpuscular
volume (MCV)

80100

Reticulocyte count

0.1%2.4% of the
total RBC count

Immature RBC; helps quantify


bone marrow production of
RBC

Erythrocyte
sedimentation
rate (ESR)

030 mm/hr

Measures the rate at which RBC


settle in uncoagulated blood
over time; alterations in
plasma proteins alter the ESR

WBC count

400011,000/mm3

WBC differential

See below for


specific
components of
differential

Neutrophils

60% PML
3% bands

Lymphocytes

30%

Estimates RBC oxygen-carrying


capacity/function
Numerically usually three times the
Hb value; also called the packed
cell volume; measures the
percentage by volume of RBC in
whole blood after use of
centrifuge
Ratio of the Hct to the RBC count

Distribution and morphology of


the WBC count consisting of
neutrophils, lymphocytes,
monocytes, eosinophils,
basophils
Phagocytic cells (mature
neutrophils) are
polymorphonuclear leukocytes
(PML) (segs)
Immature neutrophils are called
bands (stabs)

Produce antibodies and


important in immune activity

Commonly Used To Detect


Anemia, hydration status, blood
volume
Low values mean anemia
Low Hct anemia, overhydrated,
blood loss/bleeding
High Hct dehydration or unusual
blood conditions
Low MCV microcytic anemia
(e.g., iron deficiency)
High MCV macrocytic anemia (e.g.,
folate or vitamin B12 deficiency)
Percentage is decreased with
aplastic anemia
Increased in response to acute
blood loss, hemolysis, or
treatments for anemia
Increases with inflammation such
as infection, tissue infarction
(e.g., myocardial infarction),
rheumatoid or collagen diseases
Increased values usually mean
infection; leukemia and
administration of
corticosteroids can cause a
WBC increase too
Changes in the normal
distribution can indicate
certain disease,
environmental, or
inflammatory responses
When an increase in WBC occurs
with an increase in the
percentage of bands, this is
called a left shift; bandemia
often occurs in systemic
bacterial infection; can also
occur with certain viruses,
fungi, and serious stress such
as acute trauma with
hemorrhage. Inflammatory
responses and leukemia may
also cause leukocytosis
Neutropenia may be caused by
chemotherapy, drug reactions,
overwhelming infections
Increased counts occur with viral
infections; decreased counts
occur with immunodeficiency,
such as AIDS; atypical
lymphocytes appear during
infectious mononucleosis
Continued

84

SECTION I

Table 8-5

PHARMACEUTICAL PRACTICE

Hematologic Testscontd
Reference Range
(Typical Adult Range)

Comments

Commonly Used To Detect

Monocytes

4%

Phagocytic cells

Eosinophils

2%

Play a part in immune reactions

Basophils

1%

Also called mast cells; complete


function not understood

150,000300,000/
mm3

Formed elements in the blood,


vital to blood clotting

May be increased during certain


infections, such as
tuberculosis or endocarditis
Increased in acute allergy (pollen,
drug, asthma) and in some
parasitic infections
Increased counts may occur in
chronic myelogenous leukemia
(CML)
Thrombocytopenia is notable
when counts are <100,000/mm3
and severe if <50,000/mm3

Substance

Platelet count

Table 8-6

Endocrine Tests

Substance

Reference Range
(Typical Adult
Range)

Glucose (2-hour
postprandial)

80140 mg/dL

Fasting glucose

70100 mg/dL

HbA1c

4%6%

Thyroid
stimulating
hormone (TSH)

Comments

For patients with known diabetes, a


good result is usually 7%; in
some patients, a HbA1c up to
7.5% may be acceptable. Trying
to achieve normal levels may
increase risk of hypoglycemia.

Low result indicates hyperthyroid


status; high result indicates
hypothyroid status

Commonly Used to Detect


High result indicates glucose
intolerance and diabetes.
Used after glucose tolerance test in
pregnancy and to self-monitor
diabetes at home
High result indicates impaired
glucose tolerance or diabetes.
Most commonly used test for
diagnosing diabetes mellitus
(value >200) or prediabetes
(impaired glucose tolerance, value
>110 in nonpregnant or >125 if
pregnant); also used to selfmonitor diabetes at home
Reflects average glucose level over
previous 2 to 3 months, a good
indicator of glycemic control
Percentage of HbA1c found to
correlate with average blood
glucose concentrations; a result of
>7% correlates with mean plasma
glucose >200 mg/dL
Most common test to screen for
hypo- or hypothyroidism; may
be used in conjunction with free
thyroxine (T4) or other thyroid
function tests; also used to
monitor the effectiveness of
thyroid treatment regimens or
replacement hormones

CHAPTER 8

Bibliography

REVIEW QUESTIONS
(Answers and Rationales on page 337.)
A clinical coordinator at the local hospital is looking
for appropriateness of tobramycin therapy in her
institution via drug utilization review (DUR). In
addition to the serum drug concentration trends in
the reviewed patient records, what other laboratory
tests would be helpful?
I. Serum creatinine
II. Alkaline phosphatase
III. AST/ALT
IV. Cultures and sensitivities
a.
b.
c.
d.
2.

3.

4.

A young woman presents to the emergency


department with fever, pain in her chest, and a
purulent cough. She is a poor historian of health
problems. She has a small cut on her lower leg that is

Which of the following laboratory tests would be


helpful in the diagnosis of myocardial infarction?
I. Hematocrit
II. Creatine kinase (CK)
III. Lactate dehydrogenase (LDH)
IV. Albumin
V. Alkaline phosphatase
a.
b.
c.
d.
e.

I and II only
I and IV only
II and III only
All of the above

A 56-year-old man with type 2 diabetes mellitus goes


to the pharmacy to refill prescriptions after his
6 month physician visit. He is grumbling about taking
his medications and explains that his A1c was too
high. Now he has to take an additional medication.
He asks the pharmacist What is so important about
that A1c anyway? What is the best response?
a. Glucose in the urine indicates poor diabetes
control.
b. Poorly controlled diabetes can result in eye,
kidney, and vascular problems over time.
c. The HbA1c gives the doctor an indication of
blood glucose control over several months, and if
this test can be maintained at HbA1c value of 7%
or lower, the complications of diabetes (eye,
kidney, neuropathy, vascular) can be minimized.
d. It is important to prevent hypoglycemia.

85

red but not oozing. There are decreased breath


sounds at the base of the right lung. A chest x-ray
result is pending. Her white blood cell (WBC)
differential reveals:
WBC count: 15,600
PML neutrophils: 80%
Bands: 6%
Lymphocytes: 11%
Monocytes: 1%
Eosinophils: 1%
Basophils: 1%
What is the most likely explanation for this WBC
panel?
a. Bacterial infection of lung or blood
b. Neutropenia
c. A localized infection of the leg tissue
d. Acute allergic reaction to pollen

Lee M: Basic skills in interpreting laboratory data, ed 4,


Bethesda, 2009, American Society of Health-Systems
Pharmacists.
Wu A: Teitz clinical guide to laboratory tests, ed 4,
Philadelphia, 2006, Saunders.
Clinical Pharmacology, [database online] Tampa, 2009,
Resource Center, Lab Reference Values, Gold Standard,
Inc: http://www.clinicalpharmacology.com Accessed
July 16, 2009.

1.

Laboratory Tests

5.

I and IV
II and V
II and III
II and IV
All of the above

A 35-year-old woman has been maintained on 50 mcg


per day of levothyroxine, with a normal TSH of
2 mIU/L; she is monitored every 6 months and has
been stable for several years on this dosage.
Recently, she is complaining of weight gain, fatigue,
hair loss, and sensitivity to cold. A check of her
TSH reveals a result of 10 mIU/L. She appears to
have no other symptoms or findings on exam.
A careful review of medications and recent changes in
health habits reveals that she is now taking a
multivitamin with minerals every morning, which she
began 2 months ago. What is the best approach at
this time?
a. The patient is now hyperthyroid and needs
further testing.
b. Increase the dose of levothyroxine and recheck
in 6 months.
c. Separate the administration of levothyroxine
from the multivitamin with minerals by at least
several hours and recheck the TSH in 1 month.
d. Try another brand of levothyroxine.

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SECTION
..................................................

II

PHARMACOTHERAPY
IN PRACTICE

Antiinfective Agents

CHAPTER

....................................................................................................................................................................

I.

Diagnosis
A. Identify the organism
1. Gram stain differentiates bacteria based on structure and composition of the layers of the cell wall.
a) Gram positive purple stain
b) Gram negative pink stain
2. Culture and sensitivity; serologic testing
B. Laboratory tests
1. Nonspecific tests: white blood cell count with
differential
II. Initial treatment strategies
A. Empiric
1. Empiric therapy must be initiated without delay.
2. Empiric therapy is based on likely pathogens
suspected but not specifically known.
3. Empiric therapy is altered to more specific
therapies based on culture and sensitivity and
patients disease state.
B. Definitive
1. Microbiologic or serologic diagnosis with
susceptibilities known
C. Prophylaxis
1. Before surgery or procedure
2. Immunocompromised patients
III. Common infections
A. Bacteria
 Classification
Gram-positive cocci (spherical)
Staphylococcus aureus
Streptococcus pneumoniae
Enterococcus faecalis, Enterococcus faecium
Gram-positive bacilli (rods)
Clostridium perfringens, Clostridium difficile
Gram-negative cocci (spherical)
Neisseria meningitides, Neisseria
gonorrhoeae
Moraxella catarrhalis
Gram-negative bacilli (rods)
Escherichia coli
Klebsiella spp.
Enterobacter spp.
Pseudomonas aeruginosa
Bacteroides fragilis
Atypical bacteria
Chlamydia pneumonia

Mycobacteria pneumoniae
Legionella spp.

Spirochetes (spiral)
Syphilis (Borrelia burgdorferi)
Lyme disease (Treponema pallidum)
B. Fungal
1. Superficial
 Vulvovaginal candidiasis
Major pathogen: Candida albicans
 Oropharyngeal and esophageal candidiasis
Major pathogen: Candida albicans
 Mycotic infections of hair, skin, and nails
Tinea pedis (athletes foot)
Tinea cruris (jock itch)
Tinea corporis (ring worm)
Tinea capitis
Pityriasis versicolor
Onychomycosis
2. Invasive
 Candida
Caused by Candida spp. (C. albicans,
C. glabrata, C. tropicalis, C. krusei)
 Aspergillosis
Caused by Aspergillus spp.
 Histoplasmosis
Caused by H.capsulatum
 Cryptococcus
Caused by C. neoformans
 Blastomycosis
Caused by B. dermatitidis
 Coccidiomycosis
Caused by C. immitis
C. Virus
 Types of virus that cause human infection:
Influenza virus
Cytomegalovirus (CMV)
Varicella zoster virus (chickenpox, shingles)
SARS coronavirus (severe acute respiratory
syndrome [SARS])
Herpes simplex (HSV-1 and HSV-2)
Respiratory syncytial virus (RSV)
Adenovirus
Epstein-Barr virus (EBV)
Human immunodeficiency virus (HIV)
Hepatitis A, B, C, or others
87

88

SECTION II

Table 9-1

General Antibiotic Classes Used for Major


Organism Categories

Gram positive

Gram negative

Anaerobes

PHARMACOTHERAPY IN PRACTICE

Penicillin, nafcillin or oxacillin


First generation cephalosporins
Macrolides
Vancomycin
Extended pencillins or imipenem
Second and third generation
cephalosporins
Quinolones
Aminoglycosides
Metronidazole
Clindamycin

Table 9-2

Cephalosporins

Generation

Drug name

First

Cefazolin (Ancef, Kefzol)


Cephalexin (Keflex,
Keftab)
Cefadroxil (Duricef,
Ultracef)
Cephradine (Velosef)*
Cephapirin (Cefadyl)*
Cefuroxime (Ceftin,
Kefurox, Zinacef)
Cefoxitin (Mefoxin)
Cefotetan (Cefotan)
Cefprozil (Cefzil)
Cefaclor (Ceclor)
Loracarbef (Lorabid)
Cefdinir (Omnicef)
Ceftriaxone (Rocephin)
Cefotaxime (Claforan)
Ceftizoxime (Cefizox)*
Cefoperazone (Cefobid)*
Cefixime (Suprax)
Ceftazidime (Fortaz,
Tazicef, Tazidime)
Cefepime (Maxipime)

Second

Third
IV. Antimicrobial treatment (Table 9-1)
A. Penicillins
1. Mechanism of action (MOA): inhibits synthesis
of bacterial cell walls; bactericidal
2. Penicillins are classified as b-lactam antibiotics
because their structure consists of a b-lactam
ring that joins to a thiazolidine ring
3. Highly active against gram-positive cocci (e.g.,
Streptococcus), gram-positive rods (e.g., Listeria),
and gram-negative cocci (e.g., Neisseria)
a) Antistaphylococcal penicillins: nafcillin,
oxacillin, cloxacillin, dicloxacillin
b) Broad-spectrum penicillins
(1) Second-generation (amoxicillin,
ampicillin): active against most strains of
Escherichia coli, Proteus mirabilis,
Salmonella sp, Shigella sp, and
Haemophilus influenzae
(2) Third- and fourth-generation
(carbenicilin, ticarcillin, piperacillin,
mezlocillin, azlocillin): Pseudomonas
aeruginosa and indole-positive Proteus
spp, Enterobacter spp
4. Adverse effects: anaphylaxis, interstitial
nephritis, anemia, leukopenia, hepatitis
(oxacillin and nafcillin)
B. b-lactamase inhibitors
1. Exhibit no or minimal antibacterial activity of
their own
2. Used in combination products with certain
penicillins to allow coverage of b-lactamase
producing organisms that would ordinarily not
be covered by the particular penicillin (extends
antimicrobial spectrum)
3. All agents are irreversible inhibitors of
b-lactamases
4. Examples: clavulanic acid, sulbactam, tazobactam
a) Amoxicillin/clavulanic acid (Augmentin)
b) Ticarcillin/clavulanic acid (Timentin)
c) Ampicillin/sulbactam (Unasyn)
d) Piperacillin/tazobactam (Zosyn)
C. Cephalosporins (Table 9-2)
1. Mechanism of action (MOA): same as penicillins

Fourth

Route
IM, IV
PO
PO
PO, IM, IV
IM, IV
PO, IM, IV
IM,
IM,
PO
PO
PO
PO
IM,
IM,
IM,
IM,
PO
IM,

IV
IV

IV
IV
IV
IV
IV

IM, IV

*Discontinued from US market.

2. Also b-lactam antibiotics, but composed of a


dihydrothiazine and a b-lactam ring
3. In general, each successive generation has
broader gram-negative coverage.
4. First generation (cefazolin, cephadrine,
cefadroxil, cephalexin, cephapirin): activity
against staphylococci, streptococci, and
community-acquired Escherichia coli, Klebsiella,
and Proteus spp
5. Second generation (cefuroxime, cefoxitin,
cefotetan, cefprozil, cefaclor, loracarbef):
expanded coverage against enteric
gram-negative rods
a) cefuroxime: useful against Haemophilus
influenzae
b) cefoxitin, cefotetan: useful against
Bacteroides spp
6. Third generation (ceftriaxone, cefotaxime, cefdinir,
ceftizoxime, cefoperazone, cefixime, ceftazidime):
broadest coverage for enteric, aerobic gramnegative rods, and retain good activity against
streptococci other than enterococci; moderate
anaerobic activity (not B. fragilis)
a) ceftazidime: useful against Psuedomonas
aeruginosa
7. Fourth generation (cefepime): excellent aerobic
gram-negative rod coverage including
P.aeruginosa; aerobic and gram-positive
coverage is similar to third generation
a) Used as empiric therapy for febrile patients
with neutropenia

CHAPTER 9

8. Adverse effects: anaphylaxis, interstitial


nephritis, anemia, leukopenia
a) Patients should be asked about allergy to
penicillins
D. Carbapenems
1. Mechanism of action (MOA): interferes with cellwall synthesis similar to penicillins and
cephalosporins; bactericidal
2. Active against most gram-positive and gramnegative bacteria including anaerobes
a) Unlike imipenem and meropenem,
ertrapenem is not effective against
Pseudomonas and Enterobacter
3. Useful for Fourniers gangrene, intra-abdominal
infection
a) Do not use for CNS infections due to seizure risk
4. Examples: imipenem, meropenem (Merrem),
ertropenem (Invanz), doripenem (Doribax)
a) Imipenem/cilastatin (Primaxin): used IV
and IM only; combined with cilastatin because
the action of dehydropeptidase enzymes on
imipenem rapidly produces a nephrotoxic and
inactive metabolite; cilastatin prevents
dehydropeptidase degradation
5. Adverse effects: precipitate seizure activity or
confusion particularly in elderly patients or
those with seizure disorders; adjust dose in
patients with renal impairment because risk is
higher with high-dose exposure
a) Meropenem has a lower risk of seizures than
imipenem
E. Monobactams (Aztreonam)
1. Mechanism of action (MOA): interacts with
penicillin binding proteins; induces formation of
long filamentous bacteria; b-lactam ring is
isolated; bacteriocidal
2. Excellent activity against gram-negative aerobes
including Pseudomonas aeurginosa; no activity
against gram-positive aerobes; inactive against
all anaerobes
3. Should be reserved for serious gram-negative
infections in the lung, bone, urinary tract, or blood
4. Rarely exhibits cross-sensitivity with agents
from other classes of b-lactam antibiotics
5. Adverse effects: injection site reactions, nausea,
vomiting, diarrhea, rash
F. Gram-positive antibiotics
1. Vancomycin (Vancocin, Vancoled)
a) Mechanism of action (MOA): glycopeptides;
binds a D-alanyl-D-alanine precursor that is
critical for peptidoglycan crosslinking in
most gram-positive bacterial cell walls;
bacteriostatic for enterococci; bactericidal
against other susceptible isolates
b) Active against staphylococci including
methicillin-resistant staphylococcus aureus
(MRSA), enterococci, streptococci, and
Clostridium including C. difficile (when given
orally)
(1) Drug of choice for MRSA/MRSE
(2) Enterococci may be vancomycin
resistant (e.g., vancomycin-resistant
enterococci, also known as VRE)

Antiinfective Agents

89

c) Acts synergistically with aminoglycosides


against susceptible enterococci
d) Usual adult intravenous dose: 1 g over
60 minutes every 12 hours
(1) Give by slow IV infusion
(2) Adjust dose for patients with renal
impairment and in patients older than
65 years
(3) Monitor serum levels and adjust dose
accordingly
(a) Therapeutic concentrations: peak
2040 mg/L; trough 515 mg/L
e) Adverse effects
(1) Red man syndrome (flushing of the
upper body) if given at infusion rates
greater than 10 mg/min. Slow infusion
over at least 1 hour is recommended to
avoid this side effect.
(2) Nephrotoxicity and ototoxicity (often
permanent): may be increased when used
in combination with aminoglycosides
2. Linezolid (Zyvox)
a) Mechanism of action (MOA): interrupts
bacterial growth by inhibiting the initiation
of protein synthesis
b) Activity against gram-positive infections
including certain drug-resistant
enterococcus, staphylococcus (MRSA), and
pneumococcus strains
c) IV and PO forms available
d) Adverse effects: myelosuppression
(infrequent), thrombocytopenia, and
hypertension (particularly with tyraminecontaining foods)
e) Drug interactions: Avoid use with SSRIs due
to risk of serotonin syndrome
3. Quinupristin-dalfopristin (Synercid)
a) Mechanism of action (MOA): dalfopristin
blocks early step in protein synthesis;
quinupristin blocks a later step; combination
is synergistic; bactericidal
b) Active against antibiotic-resistant grampositive organisms, particularly vancomycinresistant Enterococcus faecium (VRE)
c) Adverse effects: reversible arthralgias,
myalgias, and peripheral venous irritation
d) Drug interactions: significantly inhibits the
cytochrome P-450 (CYP) 3A4 enzyme system
4. Others: Daptomycin (Cubicin)
G. Fluoroquinolones
1. Mechanism of action (MOA): inhibit bacterial
DNA gyrase and topoisomerase, which are
critical for DNA replication; bactericidal
2. Variable gram-positive activity; extensive gramnegative activity; poor anaerobic coverage;
variable atypical activity; all have high activity
against Legionella; some are effective against
anthrax
a) First generation (quinolones, naldixic acid
[NegGram]): useful for UTI caused by gramnegative rods
b) Second generation (fluoroquinolones,
ciprofloxacin [Cipro], norfloxacin

90

SECTION II

PHARMACOTHERAPY IN PRACTICE

[Noroxin], enoxacin [Penetrex]*,


ofloxacin [Floxin]): active against gramnegative aerobes; ciprofloxacin most active
against P. aeruginosa
(1) Poor activity against gram-positive cocci
and anaerobes
c) Third generation (levofloxacin [Levaquin],
sparfloxacin [Zagam]*, gatifloxacin
[Tequin]*, grepafloxacin [Raxar]*):
improved coverage of aerobic gram-positive
bacteria including streptococci,
staphylococci, and enterococci; less activity
against gram-negative bacteria than
ciprofloxacin; expanded activity against
atypical pathogens
d) Fourth generation (trovafloxacin [Trovan]*,
moxifloxacin [Avelox]): same as third
generation plus broad anaerobic coverage
3. Adverse effects: nausea, CNS disturbances,
rash, phototoxicity, QTc prolongation
a) Increased risk of developing tendinitis and
tendon rupture (class effect)
b) A longer course of treatment (more than
7 days) of gemifloxacin (Factive)
associated with serious rash, especially in
post-menopausal women on hormone
replacement therapy and in patients
younger than 40 years.
c) Many drugs in class no longer available*:
(1) Grepafloxacin* withdrawn from the
United States market by the
manufacturer due to adverse
cardiovascular events (QT prolongation)
(2) Sparfloxacin* withdrawn due to lack of
sales
(3) Trovafloxacin* withdrawn due to risk of
hepatic toxicity
(4) Gatifloxacin* withdrawn because of an
increased incidence of hypoglycemia and
hyperglycemia
4. Drug interactions
a) Antacids, calcium, mineral supplements
(divalent cations), sucralfate, and select
foods may impair the absorption of oral
quinolones.
b) Cimetidine and probenecid can inhibit renal
tubular secretion of fluoroquinolones that
are primarily eliminated through renal
excretion (except trovafloxacin).
c) Fluorquinolones can inhibit clearance of
xanthine derivatives (e.g., theophylline).
d) Some fluoroquinolones can raise
cyclosporine levels (e.g., ciprofloxacin)
e) Increase effect of warfarin
H. Macrolides
1. Mechanism of action (MOA): inhibits protein by
binding to 50S subunit of the bacterial
ribosome; bacteriostatic
2. Examples: erythromycin (E-Mycin, Ery-Tab,
Eryc, Erythrocin stearate, Ilosone, Eryped,
EES, Emgel), dirithromycin (Dynabac),
clarithromycin (Biaxin), azithromycin
(Zithromax), telithromycin (Ketek)

3. Extensive gram-positive activity; drugs of


choice for treating Legionella, Chlamydia, and
Mycoplasma infections
a) Azithromycin: more effective against
H. influenzae, Legionella and Toxoplasma
gondii than erythromycin; effective against
mycobacterium avium- intercellulare complex
(MAC); longer half-life than erythromycin
b) Clarithromycin: more effective against
H. influenzae than erythromycin; also
effective against MAC; used with other drug
for Helicobacter pylori; also useful in Lyme
disease; renally eliminated
4. Adverse effects: GI disturbances (nausea,
abdominal cramping), abnormalities in liver
function tests (LFTs)
5. Drug interactions: metabolized by CYP3A4
(exception of azithromycin); erythromycin and
clarithromycin are strong inhibitors of CYP3A4.
I. Tetracyclines
1. Mechanism of action (MOA): binds to 30S
ribosomal subunit blocking protein synthesis;
bacteriostatic
2. May be used to treat Rickettsia (Rocky Mountain
spotted fever), Chlamydia, Mycoplasma, and
Spirochete infections (Lyme disease, syphilis); may
be effective against for anthrax; used for acne and
rosacea
a) Minocycline and doxycycline are more
lipid soluble than other tetracycline
antibiotics
3. Examples: tetracycline (Sumycin, Panmycin,
Tetracyn), doxycycline (Vibramycin,
Doryx), minocycline (Minocin)
4. Adverse effects: nausea, photosensitivity; tooth
enamel discoloration in children, QTc
prolongation
5. Drug interactions
a) Concomitant administration of iron
supplements or antacids may impair the oral
absorption of tetracyclines.
b) Tetracyclines (particularly doxycycline) may
be less effective in patients receiving
anticonvulsants like phenytoin and
carbamazepine due to induction of hepatic
microsomal enzymes.
c) Tetracyclines may reduce the efficacy of oral
contraceptives.
d) Tetracyclines may enhance the
anticoagulant effect of warfarin.
J. Sulfonamides
1. Mechanism of action (MOA): inhibits folic acid
metabolism by competitively inhibiting
p-aminobenzoic acid (PABA) utilization;
bacteriostatic
2. Commonly used for uncomplicated UTI,
sinusitis, and otitis media
3. Adverse effects
a) Hemolytic anemia in glucose-6-phosphate
dehydrogenase (G6PDH) deficient patients
b) Allergy (ask patient if allergic to sulfa drugs)
c) Rash includes Stevens-Johnson syndrome
d) Kernicterus in newborns

CHAPTER 9

4. Examples
a) Silver sulfadiazine (topical)
b) Sulfadiazine
c) Sulfisoxazole
d) Sulfamethoxazole (SMZ)
e) Sulfacetamide
K. Trimethoprim (TMP; Proloprim)
1. Mechanism of action (MOA): competes with
PABA for incorporation into the pteridine
precursor molecule that leads to inhibition of
dehydropteroate synthetase enzyme
L. SMZ/TMP (Bactrim, Septra)
1. There is an increased risk of resistance when
sulfonamide antibiotics are used alone.
2. Used for Nocardia (rare pulmonary infection),
Chlamydia trachomatis, uncomplicated UTI,
burns, Pneumocystis pneumonia (PCP)
3. Adverse effects
a) Rash includes Stevens-Johnson syndrome
b) Leukopenia
c) Granulocytopenia
d) Megaloblastic anemia
e) Thrombocytopenia
M. Aminoglycosides
1. Mechanism of action (MOA): binds to bacterial
ribosome causing misreading during translation
of bacterial messenger RNA into proteins;
bactericidal
2. Active against aerobic, gram-negative bacteria;
also active against staphylococci and certain
mycobacteria. Good activity against
Pseudomonas spp.
3. Examples: gentamicin (Garamycin),
tobramycin (Nebcin), amikacin (Amikin),
kanamycin (Kantrex), neomycin
(Mycifradin), streptomycin
4. Adverse effects: nephrotoxicity, ototoxicity,
neuromuscular blockade (rare)
5. Drug interactions: aminoglycosides must be
used with extreme caution with other drugs
that may cause nephrotoxicity
N. Miscellaneous
1. Chloramphenicol (Chloromycetin)
a) Mechanism of action (MOA): binds to 50S
ribosomal subunit blocking protein
synthesis; bacteriostatic
b) Broad activity against aerobic and anaerobic
gram-positive and gram-negative bacteria
including S aureus, enterococci, and enteric
gram-negative rods; also has activity against
Rickettsia, Chlamydia, Mycoplasma, and
Spirochetes
c) Adverse effects: aplastic anemia and doserelated bone marrow suppression; gray baby
syndrome
d) Drug interactions: inhibitory effect on
CYP2C19, CYP3A4, and, to a lesser extent,
CYP2D6
2. Metronidazole (Flagyl)
a) Mechanism of action (MOA): inhibits
bacterial nucleic acid synthesis; bactericidal
b) Greater activity against gram-negative than
gram-positive anerobes but active against
Clostridium perfringens and Clostridium

Antiinfective Agents

91

difficile; also effective against amebae and


protozoa
c) Adverse effects: nausea, headache,
restlessness, disulfiram-like reactions to
alcohol, seizures (rare), peripheral
neuropathy (rare)
(1) To be used cautiously in patients with
hepatic function impairment
Antifungal agents
1. Amphotericin B desoxycholate (Fungizone);
amphotericin B lipid-based (AmBisome,
Abelcet, Amphotec)
a) Mechanism of action (MOA): binds with
ergosterol to disrupt the fungal plasma
membrane; fungicidal
b) Activity against Aspergillus, Coccidioides,
Cryptococcus, Histoplasma, and Candida
c) Lipid complex formulations of amphotericin
B (amphotericin B lipid complex, liposomal
amphotericin B, and amphotericin B
cholesterol sulfate complex) have reduced
adverse effects, including less risk of
nephrotoxicity, and less common infusionrelated reactions (chills, fever, nausea).
d) Adverse effects: nephrotoxicity (more likely
with conventional amphotericin B);
increased LFT
2. Caspofungin (Cancidas)
a) Mechanism of action (MOA): irreversibly
inhibits the enzyme 1,3D-glucan synthase,
thereby disrupting the integrity of the fungal
cell wall; fungicidal
b) Activity against Candida, Aspergillus, and
Histoplasma
c) Adverse effects: May increase LFT
3. Flucytosine (Ancobon)
a) Mechanism of action (MOA): interferes with
DNA synthesis
b) Activity against Candida and Cryptococcus
c) Adverse effects: dose-related bone marrow
suppression, hepatotoxicity
(1) Use with extreme caution in patients
with renal dysfunction
4. Griseofulvin (Frisactin, Grifulvin V, Fulvicin)
a) Activity against Trichophyton, Microsporum,
and Epidermophyton
5. Azole antifungal (itraconazole [Sporanox],
ketoconazole [Nizoral], fluconazole [Diflucan])
a) Mechanism of action (MOA): inhibits
ergosterol synthesis
b) Activity against Candida albicans
(1) Fluconazole is the drug of choice for
localized candidal infections (e.g., UTI,
thrush).
c) Interactions
(1) Ketoconazole: major substrate of
CYP A4; strong inhibitor of CYP 3A4,
CYP 1A2, and CYP 2C8, CYP 2C9;
moderate inhibitor of CYP 2A6,
CYP 2C19, and CYP 2D6
(2) Itraconazole: major substrate of CYP 3A4;
major inhibitor of CYP 3A4
(3) Fluconazole: strong inhibitor of CYP 2C19
and 2C9; moderate inhibitor of 3A4

92

SECTION II

PHARMACOTHERAPY IN PRACTICE

(4) To be avoided with cisapride due to lifethreatening arrhythmias


(5) To be used with extreme caution with
digoxin (decreased clearance of digoxin)
(6) Oral absorption of itraconazole and
ketoconazole is impaired by concomitant
antacids, H2 blockers, or proton-pump
inhibitors (PPI)
6. Terbinafine (Lamisil)
a) Mechanism of action (MOA): inhibits
ergosterol sythesis
b) Used for fungal infections of fingernail or
toenail
c) Adverse effects: LFT abnormalities, rash,
headache, GI disturbance, neutropenia (rare)
d) Interactions: strong inhibitor of CYP 2D6
7. Nystatin
a) MOA: binds to sterols on cell membrane
b) Most commonly used orally as swish/
swallow for thrush, or topically for fungal
rashes
P. Antitubercular agents
1. Effective against Mycobacterium tuberculosis
infections
a) Isoniazid (Nydrazid)
(1) Mechanism of action (MOA): kills
susceptible mycobacteria by interfering
with synthesis of lipid components of
cell wall
(2) Adverse effects: LFT elevations
(3) Interactions: major CYP 2E1 substrate;
strong inhibitor of CYP 2C19 and 3A4;
may also inhibit 1A2, 2A6, 2C9, 2D6, 2E1
b) Rifamycins (rifampin [Rifadin,
Rimactane], rifabutin [Mycobutin],
rifapentine [Priftin]): inhibits DNAdependent RNA polymerase, blocks RNA
transcription
(1) Rifampin also active against grampositive and gram-negative bacteria
(2) Adverse effects: reddish-orange
discoloration of body fluids, rash, GI
disturbances, increased LFT
(3) Interactions: strong inducer of CYP 3A4,
1A2, 2A6, 2B6, 2C8, 2C9, and 2C19
c) Pyrazinamide
(1) Mechanism of action (MOA): unknown
(2) Adverse effects: increased LFT; may
inhibit uric acid
d) Ethambutol (Myambutol)
(1) Mechanism of action (MOA): interferes
with RNA synthesis
(2) Adverse effects: optic neuritis
(decreased red-green color perception,
decreased visual acuity); hepatotoxicity
e) Capreomycin (Capastat sulfate)
(1) Mechanism of action (MOA): unknown
(2) Adverse effects: ototoxicity,
nephrotoxicity, hepatotoxicty
f) Cycloserine (Seromycin)
(1) Mechanism of action (MOA): inhibits
bacterial cell wall synthesis by
competing with D-alanine (amino acid)

(2) Adverse effects: CNS effects (drowsiness,


headache, vertigo)
g) Para-aminosalicylic acid (PAS, Paser granules)
(1) Mechanism of action (MOA): inhibits
folic acid synthesis
(2) Adverse effects: GI upset, loose stools
during initial days of treatment,
hypersensitivity reactions, vitamin and
mineral malabsorption (rare)
(a) Patients with sensitivity to tartrazine
dyes have increased risk of salicylate
sensitivity.
Antiviral agents
1. Most block viral entry into the cell or must work
inside the cell
2. Most agents are pyrimidine or purine
nucleoside analogs
3. Antiinfluenza agents
a) Amantadine (Symmetrel) and rimantadine
(Flumadine)
(1) Mechanism of action (MOA): inhibits the
uncoating of viral RNA, inhibiting
replication
(2) Used in the prevention and treatment of
influenza A (no effect on influenza B)
(3) Effective when initiated within 48 hours
of initial symptoms
(4) Fewer drug interactions with rimantadine
(5) Use of agents limited due to viral resistance
b) Zanamavir (Relenza) and oseltamivir
(Tamiflu)
(1) Mechanism of action (MOA): inhibits the
enzyme neuraminidase; inhibits
replication of influenza A and influenza B
(2) Treats uncomplicated influenza infections
(3) Relenza is administered by oral
inhalation; Tamiflu is given orally. Both
are to be initiated within 48 hours of
onset of symptoms
4. Antiherpes agents
a) Acyclovir (Zovirax): a prototype antiviral
agent
(1) Mechanism of action (MOA): inhibits
viral DNA synthesis by competition with
dGTP for viral DNA polymerase and
chain termination
(2) Used for herpes simplex virus 1 and
2 (HSV) and varicella-zoster virus (VZV)
(3) Available IV, topical, and oral
(4) Adverse effects: nausea, headache,
dizziness, reversible crystalline
nephropathy; CNS disturbances (rare)
b) Valacyclovir (Valtrex)
(1) Converted to acyclovir when ingested;
MOA same as acyclovir
(2) Used for recurrent genital herpes and
herpes zoster infection
(3) Adverse effects: nausea, CNS
disturbances (rare)
c) Penciclovir (Denavir)
(1) Mechanism of action (MOA): same as
acyclovir
(2) Used for HSV-1, HSV-2 (topical)

CHAPTER 9

d) Famciclovir (Famvir)
(1) Prodrug of penciclovir
(2) Mechanism of action (MOA): same as
acyclovir
(3) Used for HSV-1, HSV-2, VZV, Epstein-Barr
virus (EBV), and hepatitis B
e) Trifluridine (Viroptic)
(1) Mechanism of action (MOA): inhibits
viral DNA synthesis similar to acyclovir;
incorporates viral and cellular DNA
(2) Used for HSV-1 and HSV-2 (ophthalmic
drops)
f) Vidarabine (Vira-A opthalmic)
(1) Mechanism of action (MOA): inhibits
viral DNA polymerase; incorporated into
viral and cellular DNA; adenosine analog
(2) Adverse effects: tearing, mild eye irritation
5. Anticytomegalovirus agents
a) Ganciclovir (Cytovene)
(1) Mechanism of action (MOA): similar to
acyclovir; requires triphosphorylation
for activation
(2) Used for cytomegalovirus (CMV), HSV,
VZV, and EBV
(3) Adverse effects: neutropenia
b) Valgancyclovir (Valcyte)
(1) Mechanism of action (MOA): same as
gancyclovir
(2) Prodrug of gancyclovir
(3) Used for CMV
c) Foscarnet (Foscavir)
(1) Mechanism of action (MOA): inhibits
viral DNA polymeriase, RNA polymerase,
and HIV reverse transcriptase
(2) Used for HSV, VZV, CMV, EBV, human
herpesvirus six (HHV-6), hepatitis B
(HBV), and HIV
(3) Adverse effect: nephrotoxocity (avoid
with other nephrotoxic agents)
d) Cidofovir (Vistide)
(1) Mechanism of action (MOA): cytosine
analog; phosphorylation not dependent
on viral enzymes
(2) Used for CMV, HSV-1, HSV-2, VZV, EBV,
HHV-6, adenovirus, and human
papillomavirus
(3) Adverse effect: nephrotoxocity (prevented
with the administration of probenecid)
6. Antihepatitis agents
a) Lamivudine (nucleoside reverse
transcriptase inhibitor [NRTI]), for hepatitis B
b) Adefovir (NRTI), for chronic hepatitis B
c) Interferon-alfa (Pegasys, Peg-intron) and
ribavirin (Virazole, Rebetol, Copegus),
for chronic hepatitis C
d) Prevention (see Chapter 24, Immunology
and Vaccines)

References
DiPiro JT, et al: Pharmacotherapy: a pathophysiologic
approach, ed 7. McGraw-Hill Medical, 2008.
Sanford JP, et al: The Sanford guide to antimicrobial
therapy, ed 38. Antimicrobial Therapy, 2008.

Antiinfective Agents

93

REVIEW QUESTIONS
(Answers and Rationales on page 338.)
1. Which of the following antibiotics is most appropriate
for empiric treatment of bacterial meningitis?
a. Erythromycin
b. Gatifloxacin
c. Vancomycin
d. Ceftriaxone
e. Gentamicin
2. Which of the following drugs is considered a drug of
choice for Legionnaires disease?
a. Gentamicin
b. Azithromycin
c. Tetracyline
d. Oseltamivir
e. Cephalexin
3. Which of the following statements about hepatitis
A is true?
I. It is commonly spread through sharing needles.
II. It can lead to chronic hepatitis in 80% of cases.
III. A vaccine is available that will prevent infection.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

4. Aminoglycosides are used to treat all of the


following pathogens EXCEPT:
a. Escherichia coli
b. Neisseria meningitidis
c. Proteus mirabilis
d. Enterobacter aerogenes
e. Klebsiella pneumoniae
5. A young female patient begins treatment with
metronidazole for a Trichomonas infection. Which of
the following are important to monitor during her
therapy?
a. Pregnancy status
b. Alcohol use
c. Protein intake
d. a and b
e. b and c
6. Which of the following measurements should be
evaluated before implementing tobramycin therapy?
a. Serum calcium
b. Serum creatinine (SCr)
c. Urine protein
d. Serum protein
e. Serum alanine aminotransferase (ALT)
7. Which of the following pathogensis the most
commonly isolated organism in community-aquired
urinary tract infections?
a. Escherichia coli
b. Klebsiella pneumoniae
c. Staphylococcus aureus
d. Pseudomonas aeruginosa
e. None of the above

94

SECTION II

PHARMACOTHERAPY IN PRACTICE

8. Cold sores are typically caused by:


a. HSV-1
b. HSV-2
c. Varicella zoster
d. HIV
e. None of the above
9. A 60-year-old man is referred to the infectious
disease clinic with a diagnosis of tuberculosis (TB).
He was diagnosed 3 months ago and has been
treated subsequently with isoniazid, rifampin,
ethambutol, and stremptomycin. However, his
sputum contines to be positive for acid-fast bacillus
(AFB). What is the most appropriate next step?
a. Changing rifampin to rifabutin and repeating
sputum culture and sensitivity
b. Changing streptomycin to levofloxacin and
repeating sputum culture and sensitivity
c. Continuing current regimen, adding levofloxacin
and ethionamide, and repeating sputum culture
and sensitivity
d. Performing bronchoscopic lavage and biopsy
for histological analysis
e. Continuing current regimen and rechecking
sputum in 2 months
10. Trachoma is typically caused by:
a. Tinea cruris
b. Chlamydia trachomatis
c. CMV
d. A herpes virus
e. None of the above
11. Which of the following is the correct adult dose
of azithromycin for the treatment of CAP?
a. Single 500 mg dose
b. Single 2 g dose
c. 2 g per day for 3 days
d. 500 mg per day for 10 days
e. 500 mcg/kg per day for 5 days
12. All of the following are true about Vibramycin EXCEPT:
a. indicated for the treatment of uncomplicated
gonococcal infections and syphilis
b. may cause photosensitivity
c. is indicated for secretion of inappropriate
antidiuretic hormone (SIADH)
d. can impair the effectiveness of hormone
contraception
e. a and c
13. A 6-year-old boy is taken to the pediatricians office
with complaint of a face rash. On examination, the
patient has crusted bullae on the chin and jaw. The
physician diagnoses bullous impetigo. What is the
most appropriate treatment?
a. Cephalexin 50 mg/kg per day PO
b. Erythromycin 10 mg/kg per dose PO q6h
c. Dicloxacillin 50 mg/kg per day PO, in divided
doses
d. Azithromycin 10 mg/kg per day PO, given once
daily
e. a and b

14. A shingles infection most commonly appears in


which of the following areas of the body?
a. Hands and feet
b. Trunk
c. Gums
d. Mucosa
e. None of the above
15. A 40-year-old man admitted to the hospital for
community acquired pneumonia develops blood
cultures positive for Streptococcus pneumonaie.
Sensitivity testing shows intermediate susceptibility
to penicillin. What is the most appropriate
treatment?
a. Ciprofloxacin 500 mg PO bid
b. Amoxicillin 875 mg PO bid
c. Levofloxacin 500 mg PO qd
d. Erythromycin 500 mg PO qid
e. Imipenem 500 mg IV q8h
16. A 50-year-old male with a history of poorly
controlled diabetes complains of lower extremity
swelling, erythema, and tenderness. His temperature
is 39 C. The attending physician believes the patient
has a superficial diabetic foot infection involving a
limited area of the ankle and lower leg. Which of the
following is the appropriate therapy?
a. Ciprofloxacin 500 mg bid
b. Doxycycline 100 mg bid
c. Clindamycin 300 mg po qid
d. a and c
e. Admit to the in-patient ward and treat with
Levaquin 750 mg IV qd.
17. A 50-year-old woman with a history of hypertension
and a 40 pack-year smoking history presents to her
doctor with a chronic cough for the past 4 months.
She states that the cough is worse in the morning
and is occasionally productive of sputum, and she
denies fever or chills. Which of the following is the
most appropriate next step in the management of
this patient?
a. Amoxicillin/clavulanate 875 mg PO qd
b. Ciprofloxacin 500 mg PO bid
c. Sputum cultures to determine sensitivity and
specificity
d. a and c
e. No antibiotic treatment is warranted at this
time
18. A 28-year-old woman presents with symptoms of
sinusitis, including mucopurulent nasal discharge,
sinus congestion, headache, and sinus pain.
She began taking amoxicillin she found in her
medicine cabinet 3 days ago, but has had no relief.
What is the most appropriate treatment for this
patient?
a. Ciprofloxacin 500 mg PO qd
b. Erythromycin base 500 mg PO qid
c. Levofloxacin 500 mg PO qd
d. Amoxicillin/clavulanate 875 mg PO bid
e. No treatment is warranted at this time

CHAPTER 9

19. An 18-year-old man presents with symptoms of


pharyngitis. A rapid strep test is positive. He reports
severe hives with penicillin. What is the most
appropriate treatment for this patient?
a. Penicillin V 500 mg PO bid
b. Ceftriaxone 125 mg IM for one dose
c. Azithromycin 500 mg PO for one dose
d. Azithromycin 250 mg PO qd for three days
e. Azithromycin 500 mg PO for one dose, followed
by 250 mg po qd for four days
20. A 12-month-old child infant is taken to the pediatric
clinic with complaints of nonhealing otitis media.
The mother states that she took the patient to an
urgent care clinic 2 weeks ago for fever, irritability,
and anorexia, and the physician diagnosed otitis
media and prescribed erythromycin. One week later,
he did not show any improvement; she returned to
the urgent care clinic, and his prescription was
replaced with amoxicillin. Now she reports that his
symptoms have not changed. The pediatrician
confirms the diagnosis of acute otitis media. What is
the most appropriate treatment for this patient?
a. Continuing amoxicillin for another 7 days
b. Continuing amoxcillin for another 14 days
c. Replacing amoxicillin with cefuroxime 80 mg/kg/
day PO divided BID
d. Replacing amoxicillin with ceftriaxone 500 mg/kg
per day IM
e. Replacing amoxicillin with ceftriaxone 50 mg/kg
per day IM
21. A 74-year-old male nursing home resident is taken to
the emergency department for mental status
changes, poor oral intake, and lethargy. Physical
examination is essentially normal. Lumbar puncture
is performed and reveals the following:
WBC: 1200, 90% PMN
protein: 150 mg/dL
glucose: 25 mg/dL
Gram stain: gram-positive bacilli
What is the most appropriate treatment for this patient?
a. Cefotaxime
b. Gentamycin
c. Ampicillin
d. a and b
e. b and c
22. A 70-year-old woman was hospitalized for 3 weeks
after a femoral fracture and develops a urinary tract
infection. Urinalysis reveals the following:
WBC: 20
RBC: Scant
Leukocyte esterase: positive
Bacteria: many
Urine culture is positive for P aeruginosa. What is the
most appropriate antibiotic therapy at this time?
a. Moxifloxacin 400 mg PO qd for 2 weeks
b. Ampicillin 500 mg PO qd for 4 weeks
c. Ciprofloxacin 500 mg PO bid for 2 weeks
d. 160 mg trimethoprim/800 mg sulfamethoxazole
PO every 12 hours for 14 days
e. Remove the Foley catheter and repeat culture in
1 week

Antiinfective Agents

95

23. A 23-year-old woman presents with symptoms of


urinary tract infection. She is prescribed
trimethoprim/sulfamethoxazole, but returns to
the clinic in 1 week reporting no improvement.
In addition to obtaining a urine culture and
sensitivity, what is the most appropriate initial
treatment?
a. Continuing trimethoprim/sulfamethoxazole for
an additional week
b. Nitrofurantoin 100 mg PO qid for 3 days
c. Ciprofloxacin 500 mg PO bid for 7 days
d. Ciprofloxacin 250 mg PO bid for 3 days
e. Gatifloxacin 400 mg PO qid for 7 days
24. Which of the following is true about azithromycin?
I. It is classified as a macrolide antibiotic
II. It has a long duration of action
III. It is indicated for mild-to-moderate pneumonia
associated with AIDS
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

Read the case study and then answer the questions


that follow:
A 40-year-old open water fisherman comes to the ER
with a sore wrist. He reports suffering a laceration
while on the job 5 days prior. Since that time, the
wound has failed to close and has continued to
swell. On examination, his right wrist has a 1 cm
superficial wound with 5 cm surrounding area of
brown discoleration, erythema, edema, and
subcutaneous emphysema. There are several
ruptured bullae, which are leaking significant
amounts of grey watery fluid. The patient reports
that the swelling is rapidly increasing in size. He is
diagnosed with cellulitis.
25. Clostridial cellulits:
a. Does not require surgical debridement
b. Is usually preceded by local trauma
c. Can be treated on an outpatient basis
d. Is penicillin-resistant
e. All of the above
26. Which of the following are the most common cause
of cellulitis?
a. E. coli
b. Staph. epidermidis
c. Beta-hemolytic Streptococcus
d. Clostridium
e. Pasteurella multocida
27. Which of the following is an appropriate treatment
for Clostridial cellulitis?
a. Penicillin
b. Clindamycin
c. Chloramphenicol
d. a and b
e. a, b and c

96

SECTION II

PHARMACOTHERAPY IN PRACTICE

28. Which of the following is a risk factor for cellulitis?


a. Tinea pedis
b. Venous insufficiency
c. High carbohydrate diet
d. a and b
e. a, b and c

35. Which of the following is the active ingredient in


Abelcet?
a. Amphotericin B
b. Ketoconazole
c. Isradipine
d. Rifampin
e. Tetracycline

29. Which of the following does NOT increase the risk of


nephrotoxicity associated with gentamicin
treatment?
a. Cisplatin therapy
b. Age > 75 years
c. Amphotericin B therapy
d. Chronic renal insufficiency
e. All of the above increase the risk of
nephrotoxicity.

36. Which of the following statements is (are) true?


a. Clarithromycin and azithromycin are chemically
related to erythromycin.
b. Clarithromycin and azithromycin have less
incidence of gastrointestinal adverse effects.
c. Azithromycin has less drug interactions than
erythromycin.
d. All of the above.

30. Which of the following medications is NOT effective


for the treatment of P aeruginosa urinary tract
infection?
a. Trimethoprim-sulfamethoxazole
b. Norfloxacin
c. Ciprofloxacin
d. Methenamine mandelate
e. All of the above are effective.

37. Famciclovir:
a. is not useful in the prevention of recurrent
genital herpes simplex.
b. does not require dose adjustment for renal
impairment.
c. may cause dysmenorrhea.
d. is excreted predominately in the feces.
e. is rapidly metabolized to penciclovir.

31. Which of the following supplements should be


prescribed to patients treated with four-drug
regimen for active TB, and what is the symptom
associated with drug-induced deficiency?
a. Folic acid, anemia
b. Calcitriol, muscle spasms
c. Iron, anemia
d. Pyridoxine, paresthesia
e. Cyanocobalamin, anemia

38. Vision should be monitored in patients taking which


drug?
a. Aspirin
b. Hydroxychloroquine
c. Indomethacin
d. Cyclophosphamide
e. Auranofin

32. Bactroban nasal ointment should be applied


intranasally to eradicate which of the following
pathogens?
a. N. gonorrhea
b. S. aureus
c. S. pneumonia
d. H. influenzae
e. Any of the above
33. Flagyl may used to treat:
I. giardiasis
II. trichomonas
III. bacterial vaginosis
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

34. Which of the following is appropriate therapy for


P. aeruginosa infection?
a. Cefepime
b. Aztreonam
c. Cefotaxime
d. a or b
e. a or c

39. Which of the following is true about amikacin?


I. classified as a penicillin antibiotic
II. normal trough is 10 mcg/mL
III. may cause nephrotoxicity and ototoxicity
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

40. Which of the following pathogens are normally


responsible for causing otitis media?
I. H. influenzae
II. S. pneumoniae
III. P. aeruginosa
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

41. Which of the following antibiotics may inhibit


aggregation of platelets and worsen bleeding?
a. cefoperazone
b. cefamandole
c. ceftriaxone
d. cefotetan
e. all of the above

CHAPTER 9

42. A 35-year-old man with asthma presents to an urgent


care clinic with complaints of dry cough, fever,
headache, malaise, and myalgia. A rapid influenza
test is positive for influenza B. What is the most
appropriate therapy?
a. Amantadine, oral
b. Rimantadine, oral
c. Oseltamivir, oral
d. Zanamavir, inhaled
e. c and d
43. A 22-year-old woman presents to her primary care
physician with complaints of purulent vaginal
discharge, pain with intercourse, and lower pelvic
tenderness. She is admitted directly for treatment of
suspected pelvic inflammatory disease. What is the
most appropriate empiric treatment?
a. Clindamycin 900 mg IV q8h
b. Cefotetan 2 g IV q12h
c. Doxycycline 100 mg IV bid
d. a and b
e. b and c
44. Which of the following cephalosporins is most useful
in the treatment of bacterial meningitis?
a. cefprozil
b. ceftriaxone
c. cefaclor
d. cephalexin
e. cefadroxil
45. Which of the following antibiotics has the longest
duration of action?
a. azithromycin
b. gentamicin
c. amoxicillin
d. cephalexin
e. streptomycin
46. Which of the following cephalosporins can be given
without dose adjustment to a patient with impaired
renal function?
a. cephalexin
b. cefaclor
c. cefoperazone
d. cefadroxil
e. cephaloridine
47. Which of the following erythromycin formulations
is/are parenterally available?
I. Erythrocin
II. Ilotycin
III. Erycin
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

48. Which of the following drugs is/are used topically in


the treatment of vaginal infections caused by yeast?
a. Femstat
b. Monistat

c.
d.
e.

Antiinfective Agents

97

Gyne-Lotrimin
Mycelex G
All of the above.

49. Which of the following cephalosporin suspensions


should be avoided in patients with phenylketonuria?
a. cefprozil
b. cefaclor
c. cefazolin
d. cefixime
e. cephalexin
50. Diflucan is/are available in which of the following
form(s)?
I. oral tablet
II. injection
III. suspension
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II and III

51. All of the following are indicated for the treatment of


Pneumocystis pneumonia (PCP) EXCEPT?
a. Bactrim
b. Pentam
c. Mepron
d. Clindamycin
e. Erythromycin
52. Which of the following agents are useful in the
treatment of mycobacterium avium complex (MAC)?
I. Zithromax
II. Biaxin
III. Lamprene
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

53. Mycobutin is used to prevent infections caused by:


a. E. coli
b. Herpes zoster
c. N. gonorrhoea
d. Mycobacterium avium complex
e. CMV
54. Rifampin is contraindicated in patients suffering from:
a. migraines
b. jaundice
c. seizures
d. gout
e. CHF
55. Denavir is indicated for:
a. cold sores
b. HIV
c. genital herpes
d. influenza
e. CMV

98

SECTION II

PHARMACOTHERAPY IN PRACTICE

56. Which of the following antibiotic regimens is optimal


for endocarditis due to enterococcal infection?
a. gentamicin alone
b. ampicillin alone
c. ampicillin with gentamicin
d. ampicillin with vancomycin
e. None of the above
57. Seromycin is classified as a(n):
a. Antitubercular
b. Antibacterial
c. Antiviral
d. Antifungal
e. Antiparasitic
58. Which of the following organisms is typically
responsible for causing otitis externa?
a. Haemophilus influenza
b. Streptococcus pneumonia
c. Pseudomonas aeruginosa
d. Klebsiella pneumoniae
e. Escherichia coli
59. Doxycycline:
a. is the drug of choice for pneumonia
b. is used for the treatment and prevention of
leprosy
c. is used for the prevention of malaria
d. is used to treat sexually transmitted diseases
e. c and d
60. KT has watery stools and amebic dysentery. The drug
he is prescribed is causing a metallic taste. Which of
the following drugs was he most likely given?
a. metronidazole
b. nitrofurantoin
c. ciprofloxacin
d. ceftriaxone
e. amoxicillin
61. Which of the following antibiotics should be avoided
in patients with G6PD deficiency?
a. Penicillins
b. Tetracyclines
c. Cephalosporins
d. Sulfonamides
e. None of the above
62. Liver enzymes should be monitored in patients taking:
a. isoniazid
b. tetracycline
c. rifampin
d. All of the above
e. None of the above
63. Erythromycin is the preferred agent for the
treatment of:
I. Mycoplasma pneumoniae
II. Legionnaires disease
III. Streptococcus pyogenes
a.
b.

I only
III only

c.
d.
e.

I and II only
II and III only
I, II, and III

64. True or false: Aminoglycosides are effective


monotherapy against Streptococcus pneumoniae.
a. True
b. False
65. Telithromycin:
a. is a ketolide structurally related to macrolides
b. inhibits cell wall synthesis
c. is the drug of choice for Lyme disease
d. All of the above
e. None of the above
66. Which of the following statements about imipenem
is true?
a. It is contraindicated in patients with penicillin
allergy.
b. It is active against gram-negative rods.
c. It has broad antimicrobial activity.
d. Pseudomonas resistance has been
reported.
e. All of the above
67. Which of the following demonstrate bactericidal
activity in vitro?
a. Penicillins
b. Cephalosporins
c. Clindamycin
d. a and b
e. a and c
68. Which of the following statements is FALSE
regarding cephalosporins?
a. Enterococcus is sensitive to cephalosporins.
b. Cephalosporins depress beta-lactamase activity
in some organisms.
c. Beta-lactamase binds cephalosporins.
d. Third-generation cephalosporins have more
activity against gram-negative organisms.
e. All of the above are true.
69. Which of the following could be used to treat
methicillin-resistant Staph. aureus?
a. Piperacillin
b. Gentamicin
c. Oxacillin
d. Streptomycin
e. Vancomycin
70. Which of the following statements regarding
cefazolin is true?
a. It may be administered at 8-hour dosing intervals.
b. It has a favorable pharmacokinetic profile.
c. It has a relatively long half-life.
d. It has a lower overall cost.
e. All of the above
71. Tetracyclines:
a. can be used to treat rickettsial infections.
b. are bactericidal in vitro.

CHAPTER 9

c.
d.
e.

interfere with cell wall synthesis.


a and b
a and c

72. Which of the following antimicrobials has little


activity against anaerobes?
a. Metronidazole
b. Clindamycin
c. Imipenem
d. Ceftriaxone
e. Amoxicillin/clavulanate
73. Penicillin:
a. penetrates the blood-brain barrier well.
b. has a 30-minute half-life.
c. is excreted by the kidneys.
d. a and b
e. b and c
74. A patient with a severe penicillin allergy may:
a. have a reaction to any cephalosporin.
b. have a reaction to broad-spectrum
antipseudomonal penicillin.
c. take cephalosporins without worry of a
reaction.
d. a and b
e. b and c
75. Which of the following may occur with
chloramphenicol administration?
a. Pancytopenia
b. Erythroid suppression of bone marrow
c. Gray baby syndrome
d. All of the above
e. None of the above
76. Vancomycin:
a. can be used to treat MRSA.
b. can be used to treat C. difficile colitis.
c. is ototoxic.
d. requires dose adjustment in renal impairment.
e. All of the above
77. Inappropriate and poorly planned antibiotic use may:
a. increase infection rate.
b. increase adverse effects.
c. affect normal hospital flora.
d. increase cost.
e. All of the above
78. What is the first line therapy for Strep. pneumoniae?
a. Penicillin
b. Cefriaxone
c. Vancomycin
d. Gentamicin
e. Erythromycin
79. Aminoglycosides are:
a. bactericidal.
b. nephrotoxic.
c. renally excreted.
d. toxic to the vestibulocochlear nerve.
e. All of the above

Antiinfective Agents

99

80. Clindamycin can be used against:


a. gram-negative organisms.
b. gram-positive organisms.
c. anaerobes.
d. a and b
e. b and c
81. Amphotericin B:
a. is nephrotoxic.
b. is hydro- and lipophilic.
c. should first be administered in a test dose.
d. binds sterols in fungal membranes.
e. All of the above
82. Sulfonamides:
a. should not be used with para-amino benzoicacid (PABA).
b. prevent bacterial folic acid synthesis.
c. do not affect mammalian cells.
d. act synergistically with trimethoprim.
e. All of the above
83. Which of the following is a common early side effect
of penicillin?
a. Skin rash
b. Constipation
c. Loss of concentration
d. Orthostatic hypotension
e. Drowsiness
84. Aminoglycosides:
a. require dose adjustment in renal insufficiency.
b. may act synergistically with penicillin.
c. should not be used for anaerobic infections.
d. can be used in gram-negative aerobic infections.
e. All of the above
85. Ciprofloxacin is available in which of the following
form(s)?
I. oral tablets
II. intravenous solutions
III. topical ointment
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

86. Which of the following is NOT a beta-lactam or


related antibiotic?
a. meropenem
b. aztreonam
c. vancomycin
d. ceftriacone
e. ampicillin
87. Which of the following agents does NOT have activity
against vancomycin-resistant Enterococcus faecium?
a. linezolid
b. daptomycin
c. tigecycline
d. doxycycline
e. quinuprisitn/dalfopristin

100

SECTION II

PHARMACOTHERAPY IN PRACTICE

88. Which of the following quinolone antibiotics has the


greatest activity against Pseudomonas aeruginosa?
a. Moxifloxacin
b. Levofloxacin
c. Gatifloxacin
d. Ciprofloxacin
e. Gemifloxacin

96. Which of the following may produce drug-induced


lupus?
a. Ethambutol
b. Isoniazid
c. Tetracycline
d. Para-amino salicylic acid
e. Streptomycin

89. Which of the following bacteria alters the


composition of the peptide side chain of
peptidoglycan to cause resistance to vancomycin?
a. Neisseria meningitidis
b. Streptococcus pneumoniae
c. Haemophilus influenzae
d. Enterococcus faecalis
e. Borrelia burgdorferi

97. Which of the following statements about isoniazidinduced hepatotoxicity is true?


a. It is associated with fever, rash, and
eosinophilia.
b. It is more common in patients concomitantly
receiving ethambutol.
c. It is more common in patients younger than
20 years.
d. It is due to a hydrazine metabolite.
e. All of the above

90. Which of the following agents is NOT useful in the


treatment of enterococcal infections?
a. cefazolin
b. penicillin
c. vancomycin
d. ampicillin
e. linezolid
91. Which of the following carries a risk of ophthalmic
toxicity?
a. Ethambutol
b. Isoniazid
c. Streptomycin
d. Rifampin
e. All of the above
92. Which of the following agents targets the bacterial
ribosome?
a. isoniazid
b. vancomycin
c. tetracycline
d. levofloxacin
e. all of the above
93. Which of the following may cause drug-induced
hepatitis?
a. Ethambutol
b. Isoniazid
c. Tetracycline
d. Penicillin G
e. Kanamycin
94. Which of the following may cause both renal and
otoxocity?
a. Ethambutol
b. Isoniazid
c. Tetracycline
d. Penicillin G
e. Kanamycin
95. Which of the following may interfere with the ability
to detect the color green?
a. Ethambutol
b. Isoniazid
c. Tetracycline
d. Para-amino salicylic acid
e. Streptomycin

98. Pyrazinamide is used to treat infections caused by?


a. Mycobacterium tuberculosis
b. Mycobacterium leprae
c. Mycobacterium avium complex
d. Legionella pneumophila
e. Rickettsia rickettsii
99. Which of the following may cause hyperuricemia?
a. Rifampin
b. Ethambutol
c. Isoniazid
d. Pyrazinamide
e. Streptomycin
100. Which of the following inhibits bacterial cell wall
synthesis?
a. Rifampin
b. Ethambutol
c. Isoniazid
d. Pyrazinamide
e. Streptomycin
101. Which of the following is the most significant side
effect associated with ethambutol?
a. Hepatitis
b. Retrobulbar neuritis
c. Renal tubular acidosis
d. Agranulocytosis
e. Stevens-Johnson syndrome
102. Which of the following is NOT a first-line agent in the
treatment of tuberculosis?
a. Rifampin
b. Ethionamide
c. Isoniazid
d. Pyrazinamide
e. Streptomycin
103. Which of the following drugs are bacteriostatic?
a. Chloramphenicol
b. Tetracycline
c. Spectinomycin
d. a and c
e. a, b, and c

CHAPTER 9

104. Which of the following is/are true about famciclovir?


I. It is prodrug of penciclovir
II. It is available as oral tablet
III. It is commonly used for CMV
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

105. Ganciclovir is available in which of the following


form(s):
I. oral capsules
II. injection
III. implant
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

106. The mechanism of action of primaquine is to:


a. disrupt mitochondria.
b. bind DNA.
c. eliminate exoerythrocytic malaria.
d. a and b
e. a, b and c
107. True or False: Cryptococcus is susceptible to
amphotericin B.
a. True
b. False
108. True or False: Clotrimazole acts via inhibition of
fungal cell membrane synthesis.
a. True
b. False
109. Which of the following can most commonly cause
otitis media?
a. Escherichia coli
b. Legionella pneumophila
c. Enterobacter aerogenes
d. Haemophilus influenzae
e. Pseudomonas aeruginosa
110. The most common symptoms of acute lower urinary
tract infections are:
a. burning on urination, urgency, and frequency.
b. fever and chills.
c. numbness and flank pain.
d. headache.
111. Which of the following may be used for
aspergillosis?
I. Ketoconazole
II. Itraconazole
III. Amphotericin B
a.
b.

I only
III only

c.
d.
e.

Antiinfective Agents

101

I and II
II and III
I, II, and III

112. Which of the following drugs represent primary


agents of treatment in patients with TB?
a. Isoniazid and rifampin
b. Penicillin and ethambutol
c. PASA and cycloserine
d. Streptomycin and PASA
e. Ethambutol and ciprofloxacin
113. A 32-year-old woman with gonorrhea has a penicillin
allergy. Which of the following may be used to treat
her condition?
a. Ceftriaxone
b. TMP/SMX
c. Streptomycin
d. Cefoxitin
e. None of the above
114. Pneumocystis pneumonia (PCP) is best treated with:
a. trimethoprim/sulfamethoxazole
b. ciprofloxacin
c. ethambutol
d. penicillin
e. rifampin
115. E coli is best described as:
a. a fungus
b. a gram-negative bacilli.
c. a gram-positive cocci.
d. a virus.
e. None of the above
116. Which of the following statements regarding
penciclovir is true?
I. It is a antiviral agent used for herpes labialis.
II. It is used at the first sign of fever blister.
III. It is applied every 2 hours.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

117. Accepted regimens for the treatment of H. pylori may


contain each of the following agents EXCEPT:
a. Metronidazole
b. Ceftriaxone
c. Amoxicillin
d. Clarithromycin
e. Bismuth subsalicylate
118. Which of the following oral antibiotics is commonly
associated with pseudomembranous colitis?
a. Clindamycin
b. Ceftriaxone
c. Vancomycin
d. Linezolid
e. Ampicillin

102

SECTION II

PHARMACOTHERAPY IN PRACTICE

119. Which of the following statements regarding


tetracycline are true?
a. It is effective against rickettsial species.
b. Phototoxic reactions are possible.
c. It should be taken with food to avoid
gastrointestinal upset.
d. It is mainly bacteriostatic but can be
bactericidal at high concentrations.
e. All of the above
120. Which of the following cephalosporins are
associated with disulfiram-like reactions with
ethanol?
a. Cefoperazone
b. Cefamandole
c. Cefmetazole
d. Cefotetan
e. All of the above
121. All of the following are considered third-generation
cephalosporins EXCEPT:
a. cefdinir
b. cetriaxone
c. cefepime
d. cefixime
e. cefibuten
122. A 21-year-old, HIV-positive man presents to the
HIV clinic for examination. A tuberculosis skin
test (PPD test) is placed, and when he returns to
clinic 3 days later and is found to be positive.
His LFTs are normal, and anti-TB therapy is started.
In addition to clinical evaluation for adverse
events, what is the most appropriate monitoring
regiment?
a. Only clinical examination and interviewing is
needed
b. LFT monthly
c. LFT every 8 weeks
d. LFT at 2, 4, and 6 weeks
e. None of the above
123. All of the following are classified as gram-positive
organisms EXCEPT?
a. Staphylococcus aureus
b. Streptococcus pyogenes
c. Pseudomonas aeruginosa
d. Bacillus anthracis
e. Listeria monocytogenes

Read the case study and then answer the questions


that follow.
A 40-year-old man presents to his physician with a
3 day history of fever, productive cough, and chest
pain. He reports shortness of breath with minimal
exertion and generalized fatigue. He has no other
medical problems. On examination, he is found to have
a temperature of 101  F and decreased breath sounds
over the right lower lung lobe. Chest x-ray reveals
consolidation of the right lower lobe. Laboratory
testing shows a white blood cell count of 15,000.
124. Which of the following is a common cause of
community-acquired pneumonia (CAP)?
a. H. influenza
b. E. coli
c. Streptococcus bovis
d. Pneumocystic carinii
e. Toxoplasma gondii
125. Which of the following is an indication to consider
hospital admission in patients with CAP?
a. Systolic blood pressure <120 mm Hg
b. Blood urea nitrogen >10 mg/dL
c. Mental status changes
d. Age <40 years
e. All of the above
126. Which of the following is appropriate empiric
therapy for this patient?
a. Azithromycin
b. Vancomycin
c. Rifampin
d. Trimethoprim
e. Amoxicillin
127. Azithromycin:
a. inhibits bacterial cell wall synthesis.
b. inhibits RNA-dependent protein synthesis.
c. inhibits mitosis.
d. binds to the 30s ribosomal subunit.
e. Blocks transcription
128. Which of the following is an appropriate indication
for vancomycin?
a. Pseudomembranous colitis
b. Atypical community-acquired pneumonia
c. Staphylococcus enterocolitis
d. a and b
e. a and c

..................................................

Cardiovascular Disorders

10
CHAPTER

....................................................................................................................................................................

I.

II.

Introduction
A. Heart disease is the leading cause of death in the
United States.
B. Common heart diseases
1. Hypertension
2. Coronary artery disease (CAD)
3. Cardiac arrhythmias
4. Lipid disorders
5. Congestive heart failure
C. Diagnostic tests used to evaluate cardiovascular
function
1. Electrocardiogram (ECG)
2. Blood tests
3. Auscultation
4. Exercise stress tests
5. Chest x-ray
6. Cardiac catherization
7. Angiography
8. Doppler studies
D. Treatment
1. Dietary modification
a) Dietary Approach to Stop Hypertension
(DASH) dietdietary plan to help reduce
sodium intake
b) Low sodium intake
2. Exercise
a) Moderately intense aerobic activity for at
least 30 minutes on most days of the week
3. Smoking cessation
4. Alcohol modification
5. Drug therapy
Hypertension
A. Nearly one in three adults in the United States has
hypertension.1
B. Essential hypertension develops when blood
pressure is consistently greater than 140/90 mm Hg.
1. For patients with diabetes or chronic kidney
disease, diagnosis of hypertension is made with
blood pressure >130/80 mm Hg on at least two
separate occasions (Table 10-1).
C. Risk factors
1. Age (>45 years, men; >55 years, women)
2. Obesity (body mass index [BMI] >30)
3. Race (African American)
4. Sex (men)
5. Unhealthy lifestyle
a) Sedentary lifestyle
b) Smoking
c) Alcohol
d) High sodium intake

6. Stress
7. Family history
D. Classes of antihypertensive drugs
1. Diuretics
a) First-line therapy (e.g., thiazides)
(1) Notably, lower doses are demonstrated
to be efficacious, with a lower incidence
of side effects.
(2) Favorable cost
b) Examples
(1) Thiazide: hydrochlorothiazide (HCTZ)
(2) Loop: furosemide (Lasix),
torsemide (Demadex), ethacrynic
acid (Edecrin)
(3) Potassium-sparing: amiloride
(Midamor), spironolactone
(Aldactone), triamterene (Dyrenium),
Eplerenone (Inspra)
c) Mechanism of action
(1) Initial reduction of total blood volume
and thus cardiac output; peripheral
vascular resistance may increase
(2) When cardiac output returns to normal,
peripheral vascular resistance may
increase
(3) Depletes sodium
d) Side effects
(1) Depletes potassium (except potassiumsparing diuretics)
(2) Increases uric acid
(3) Increases lipid concentrations
(4) Gynecomastia with spironolactone
2. Calcium channel blockers
a) Examples
(1) Dihydropyridines
(a) Nifedipine (Procardia/Adalat),
amlodipine (Norvasc), felodipine
(Plendil), nicardipine (Cardene),
nisoldipine (Sular)
(2) Nondihydropyridines
(a) Diphenylalkylamines: verapamil
(Calan/Isoptin and many others)
(b) Benzothiazepines: diltiazem
(Cardizem and many others)
b) Mechanism of action
(1) Blocks entry of calcium through L-type
channels located on the vascular
smooth muscle, cardiac myocytes, and
cardiac nodal tissue (sinoatrial and
atrioventricular nodes)
103

104

SECTION II

Table 10-1

PHARMACOTHERAPY IN PRACTICE

Blood Pressure (BP) Classification

Category
Normal
Prehypertension
Stage 1 hypertension
Stage 2
hypertension

Systolic BP/
Diastolic BP (mm Hg)

Lifestyle Modification

Drug Therapy

<120/<80
120139/8089
140159/9099
160/100

Encourage
Yes
Yes
Yes

Not needed
No compelling evidence
Thiazide diuretic, usually first line
Two drug combo, usually thiazide diuretic
plus angiotensin-converting enzyme
inhibitor, angiotensin receptor blocker,
beta-blocker, or calcium channel blocker

From Joint National Committee on Prevention Detection, Evaluation, and Treatment of High Blood Pressure: The seventh report of the Joint
National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, JAMA 289:25602572, 2003. Copyright #
(2003) American Medical Association. All rights reserved.

(2) Causes vascular smooth muscle


relaxation
(3) Decreases systemic vascular resistance,
which lowers arterial blood pressure
c) Side effects
(1) Nifedipine: flushing, headache,
hypotension, peripheral edema (due to
vasodilation), nausea, heartburn, muscle
cramps, nervousness, fatigue; immediateacting nifedipine may cause severe
hypotension; sustained-release form is
recommended for maintenance dosing
(due to vasodilation).
(2) Verapamil: constipation, dizziness, fatigue
(3) Diltiazem: well tolerated; may see
hypotension, headache, dizziness
(4) Felodipine: headache
(5) All calcium channel blockers: use
cautiously in patients with congestive
heart failure (CHF); avoid
dihydropyridines in patients with CHF
d) Interactions
(1) Calcium channel blockers and other
hypotensive medications may increase
hypotension.
(2) The dihydropyridines are not inhibitors
of the cytochrome P-450 (CYP) 3A4
isoenzyme; however, they are substrates
and should be used cautiously in
patients taking drugs
such as ketoconazole, ritonavir,
or erythromycin.
(3) Diltiazem and verapamil are potent
CYP 3A4 inhibitors.
3. Angiotensin-converting enzyme (ACE)
inhibitors
a) Examples
(1) Active molecules: lisinopril (Prinivil/
Zestril), captopril (Capoten)
(2) Prodrugs: enalapril (Vasotec), benazepril
(Lotensin), ramipril (Altace), quinapril
(Accupril)
b) Mechanism of action

(1) Inhibits angiotensin II formation


(2) Competitive inhibition of ACE reduces
circulating angiotensin II, thereby
reducing vascular tone
c) Drugs of choice in patients with diabetes
mellitus or CHF
d) More effective in white patients versus black
patients
e) Efficacy is enhanced by diuretics
f) Side effects
(1) Dry cough, hyperkalemia, skin rash,
proteinuria, angioedema
(2) Use cautiously in patients with renal
insufficiency or renal artery stenosis
4. Angiotensin II receptor blockers (ARB)
a) Examples
(1) Losartan (Cozaar), valsartan (Diovan),
telmisartan (Micardis), irbesartan
(Avapro), olmesartan (Benicar),
candesartan (Atacand), eprosartan
(Teveten)
b) Mechanism of action
(1) Competitive inhibitor of AT1 receptors
(2) Blocks the ability of angiotensins II and
III to stimulate pressor and cell
proliferative effects; does not affect
bradykinin
c) Used in patients who cannot tolerate ACE
inhibitors
5. Beta blockers
a) Examples
(1) Propranolol (Inderal): antagonizes
beta-1 and beta-2; inhibits renin
production
(2) Metoprolol (Lopressor/Toprol XL): less
beta-2 antagonism; may be used in
patients with asthma, diabetes, or
peripheral vascular disease
(3) Nadolol (Corgard), carteolol (Cartrol),
atenolol (Tenormin), betaxolol
(Kerlone), bisoprolol (Zebeta): beta-1
selective antagonist; slower metabolism
and longer half-life

CHAPTER 10

(4) Acebutolol (Sectral) and pindolol


(Visken) have intrinsic
sympathomimetic activity (ISA)
(5) Labetalol (Normodyne/Trandate),
carvedilol (Coreg): alpha and beta blocker
(a) Labetolol has some beta-2 agonist
activity; may be used in
hypertensive emergencies
(b) Carvedilol used in CHF
b) Mechanism of action
(1) Reduces cardiac output
(2) Inhibits renin release
c) Side effects
(1) Fatigue, weakness, trouble sleeping; may
increase triglycerides and decreases
high-density lipoprotein (HDL)
cholesterol; hypoglycemia
(2) Bronchoconstriction: highest risk in
patients with obstructive pulmonary
disease
(3) Arrhythmias: must taper medication
when ending therapy
(4) Sexual impairment (men, exact
mechanism unknown)
(5) Overdose: bradycardia, hypotension,
bronchospasm, acute cardiac failure,
death
(6) Use cautiously in patients with CHF,
diabetes, or hyperthyroidism
d) Interactions
(1) Beta blockers and other hypotensive
medications: possible increased
hypotension
(2) Beta blockers and diabetes medications:
possible increased risk of hypoglycemia
(3) Propranolol is a substrate of CYP1A2
and 2D6 (major); CYP1A2 inducers (e.g.,
carbamazepine, rifampin) may decrease
the levels and effects of propranolol;
CYP1A2 inhibitors (e.g., ciprofloxacin,
amiodarone) may increase levels and
effects of propranolol.
6. Peripheral alpha blockers
a) Examples
(1) Prazosin (Minipress/Vasoflex), terazosin
(Hytrin), doxazosin (Cardura)
b) Competitive antagonists for alpha-1
c) Side effects
(1) Reflex tachycardia
(2) First-dose syncope
7. Vasodilators
a) Examples
(1) Hydralazine (Apresoline), minoxidil
(Loniten), sodium nitroprusside
(Nitropress)
b) Mechanism of action
(1) Relaxes smooth muscle of arterioles and
some veins
c) Side effects
(1) Reflex tachycardia, sodium retention
(2) Nitroprusside may cause cyanide ion
production
(3) Minoxidil causes excess hair growth

Cardiovascular Disorders

105

8. Central alpha-adrenergic agonists


a) Clonidine, guanabenz, guanfacine: directacting alpha-2 agonists
b) Methyldopa: prodrug taken up by central
adrenergic neurons and converted to
alpha-2 adrenoceptor agonist amethylnorepinephrine
c) Not generally used as monotherapy
d) Clonidine (Catapres)
(1) Also useful in diagnosis of
pheochromocytoma
(2) Lipid soluble; readily enters the brain
(3) Available as a sustained-release
transdermal patch
e) Side effects
(1) Sedation, dry mouth, sodium, and water
retention
(2) Withdrawal syndrome (not with
transdermal patch)
(3) Avoid in patients who are taking tricyclic
antidepressants (TCAs)
E. Special considerations regarding drug selection
1. Thiazide diuretics
a) Favorable: may slow demineralization in
osteoporosis
b) Unfavorable: may worsen gout
2. Beta blockers
a) Favorable: useful for migraine and essential
tremor (propanolol)
b) Unfavorable: Should not be used in patients
with asthma or heart block
3. Alpha blockers
a) Favorable: useful in benign prostatic
hyperplasia (BPH)
4. Loop diuretics
a) Favorable: More effective in lowering blood
pressure than thiazides in patients with
renal insufficiency
F. Special populations
1. African Americans
a) Typically associated with low renin,
expanded volume, and sensitivity to salt
b) Drugs of choice: Thiazide diuretics and longacting calcium channel blockers
c) ACE inhibitors, ARB, and beta blockers alone
are less effective in lowering blood pressure
in African Americans
2. Pregnancy
a) Drug of choice: methyldopa (based on longterm data of safety)
b) ACE inhibitors and ARB contraindicated
III. Coronary Artery Disease
A. Coronary artery disease (CAD) includes
1. Angina pectoris (chest pain): occurs when there
is a deficiency of oxygen for the heart muscle
a) Angina occurs when the blood or oxygen
supply to the myocardium is impaired and/
or the heart is working harder than usual to
supply oxygen
2. Myocardial infarction (MI) (heart attack):
occurs when a coronary artery is obstructed,
which leads to prolonged ischemia that results
in death or damage to heart muscle tissue

106

SECTION II

PHARMACOTHERAPY IN PRACTICE

a) Characterized by persistent chest pain


radiating down the left arm, weak pulse,
pallor
B. Drug therapy
1. Organic nitrates
a) Examples
(1) Nitroglycerin (e.g., Nitrolingual, Nitrotime, Nitrobid, Nitrol, Nitrostat,
Nitroguard, Nitro-Dur) (Figure 10-1)
(2) Isosorbide mononitrate (Imdur, Ismo,
Monoket)
(3) Isosorbide dinitrate (Isordil, Dilatrate
SR)
b) Mechanism of action: Exact mechanism not
known
(1) Relax vascular smooth muscle
vasodilation
(2) Metabolized to nitric oxide
vasodilation
(3) Vasodilation venous pooling
# preload
(4) # peripheral venous return venous
pooling # venous return to heart
# preload
(5) " total coronary blood flow (coronary
vasodilation)
c) Indications
(1) Acute relief of angina pectoris,
prophylaxis of anginal attacks, long-term
prophylaxis of angina pectoris

C
Figure 10-1Nitroglycerin dosage forms. (Drug photos provided by
Gold Standard, Inc.)

(2) Nitroglycerin is the drug of choice for


acute angina pectoris attacks
d) Contraindications
(1) Severe anemia
(2) Previous reaction to nitrates
(3) Caution: increased intracranial pressure,
diuretic-induced fluid depletion, severe
hypotension
e) Interactions
(1) Nitrates and alcohol: may increase
hypotension
(2) IV nitroglycerin and heparin: may need
to increase heparin dose
(3) Antihypertensive medications and
nitrates: may increase hypotension
(4) CONTRAINDICATED: Concurrent use
with sildenafil (Viagra, Revatio) or
other phosphodiesterase-5 inhibitors
(commonly used for erectile
dysfunction): may increase
hypotension, cause MI or death (severe
cases)
f) Toxicity and side effects
(1) Headache is the most common side effect
(2) Postural hypotension
(3) Facial flushing
(4) Tachycardia (rapid heart rate)
(5) Tolerance: Patients should have a nitratefree interval; Minimal time period not
known, but can range 614 hours.
2. Beta blockers
a) Mechanism of action
(1) Block beta-1 receptors in the heart and
vascular smooth muscle (some are not
selective)
(a) Negative chronotropic activity
decreases rate of heart
(b) Negative inotropic activity
decreases work of heart
b) Indications
(1) Chronic stable angina pectoris
3. Ischemic chest pain
a) MONAacronym for the primary
emergency treatments recommended as
follows:
(1) Morphine
(a) Drug of choice to relieve pain
associated with acute MI
(b) Dose: 24 mg IV push; repeat doses
every 5 to 10 minutes until pain
relief is obtained
(2) Oxygen
(a) Reduces ST elevation and limits
ischemic myocardial injury
(b) May be administered by nasal
cannula and mask
(c) Amount of oxygen is determined by
oxygen saturation
(3) Nitroglycerin
(a) Preferred drug initially for treatment
of ischemic pain
(b) Dose: 0.30.4 mg nitroglycerin
sublingually given three times at

CHAPTER 10

5 minute intervals as long as blood


pressure is stable
(c) Contraindicated in patients with
right ventricular infarction or when
heart rate is <50 beats per minute
(4) Aspirin
(a) Antiplatelet effect, which prevents
subsequent thrombus formation
(Figure 10-2)
(b) Dose: 160325 mg given by mouth as
soon as possible; chewable aspirin is
preferred
4. Calcium channel blockers
a) Mechanism of action
(1) Inhibit movement of extracellular calcium
ions across membranes of myocardial
cells and vascular smooth muscle cells
without changing serum calcium
concentration
(2) Decreases myocardial contractility
decreased work of heart
(3) Relax vascular smooth muscle
decreased afterload
b) Indications
(1) Prinzmetal variant angina, chronic
stable angina (not first choice)
5. Ranolazine (Ranexa)
IV. Arrhythmias
Arrhythmia is an abnormal conduction of the heart, may
be an atrial or ventricular problem. Ventricular
arrhythmias are more serious than atrial. Electrolytes
should be checked and corrected if abnormal. Some
patients require mechanical treatment: defibrillator;
current models may have a pacemaker. Patients should

Cardiovascular Disorders

know which type of defibrillator they have and when it


was placed in their body.
A. Atrial: arrhythmia occurring in the atria
1. Atrial fibrillation (Afib): most common
supraventricular arrhythmia, overall incidence
approximately 2% (older than 75 years old,
incidence may be as high as 10%); extremely
active and disorganized atrial activation leads
to loss of atrial contraction and lower
ventricular contraction and response.
a) Acute treatment: If the patient is considered
hemodynamically unstable, give electrical
cardioversion or medication; If the patient is
considered hemodynamically stable, use
electrical cardioversion or medication; may
require chronic treatment
b) Chronic treatment: medication to maintain
cardioversion; warfarin (Coumadin) to
prevent potential coagulation problems
2. Atrial flutter (Aflutter): less frequent than Afib,
similar in consequences and treatment;
difference is that there are rapid beats, but
atrial activation is normal; it is a disorder of
atrial pulse formation, most commonly
resulting from localized atrial reentry or ectopic
focus in lower part of right atrium.
B. Ventricular: arrhythmia occurring in the ventricle
1. Ventricular tachycardia (Vtach): most
commonly encountered life-threatening
arrhythmia; episode usually constituted by at
least three successive ventricular ectopic beats
>100/min; QRS complex is wide. Usually a
regular rhythm; conduction from ventricle to
atria may occur, resulting in retrograde atrial
Abciximab blocks the final stage of
platelet aggregation.

Platelets
Ticlopidine and clopidogrel interfere with
platelet adhesion and aggregation.

Arachidonic acid

Dipyridamole inhibits platelet aggregation.


Aspirin inhibits platelet aggregation.

Aspirin

PG intermediates

TX synthesis

Aspirin

Aspirin

PG: Prostaglandins
TX: Thromboxane

Figure 10-2Action for antiplatelet drugs.

107

(Modified from Lilley LL, Harrington S, Snyder JS: Pharmacology


and the nursing process, ed. 5, St. Louis, 2007, Mosby. In Mosou K, Snipe K: Pharmacology for pharmacy
technicians. St. Louis, 2009, Mosby.)

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depolarization. Coronary artery disease with MI


is the most common structural heart disease
predisposing to Vtach; symptoms palpitations,
breathlessness, lightheadedness, angina,
syncope.
a) Hemodynamically unstable: electrical
cardioversion
b) Hemodynamically stable: chemical
cardioversion; can start lidocaine,
procainamide, bretylium, amiodarone
2. Ventricular fibrillation (Vfib): chaotic
ventricular rhythm; no organized electrical
activity, no ventricular contraction, patient
requires immediate medical attention to prevent
death; any structural, toxic, or metabolic
derangement adversely affecting ventricular
repolarization may predispose patient to Vfib;
immediate electrical cardioversion necessary
or use medical cardioversion
a) Correct reversible causes (e.g.,
hypomagnesemia, hypokalemia). If occurring
within the first 72 hours of an acute MI and
not associated with increased risk of
recurrence, chronic drug therapy is not
required.
b) Other: mechanical defibrillator implanted
and/or chemical prophylaxis
C. Antiarrhythmic therapies (Vaughan Williams
antiarrhythmic classification)
1. Class I: inhibit fast sodium channels
a) Class Ia: prolong ventricular refractoriness
and QT interval
(1) Quinidine: suppress symptomatic atrial
premature depolarizations and complex
ventricular ectopy, convert Afib to sinus
rhythm and prevent recurrence,
terminate and prevent paroxysmal
supraventricular tachycardia (PSVT),
may prevent recurrence of sustained
Vtach or Vfib in some patients.
(2) Procainamide: same effects as quinidine
on automaticity, conduction, and
refractoriness; major metabolite: Nacetylprocainamide (NAPA) has class III
action; may be as effective as lidocaine
in acute termination of sustained Vtach
(3) Disopyramide: slows conduction and
prolongs refractoriness; similar to
procainamide and quinidine
b) Class Ib: less potent sodium channel
blockers; shorten action potential duration
and refractoriness
(1) Lidocaine: effective in management of
Vtach, especially in setting of acute MI,
not to be used as prophylaxis when
patient has an MI
(2) Mexiletine: similar to lidocaine, but has
less-potent antiarrhythmic activity; can
be used alone or with class Ia
medication; has not been shown to be
effective in preventing recurrence of
sustained life-threatening ventricular
arrhythmias when used alone

(3) Tocainide: alone or with class Ia drugs


for treatment of ventricular arrhythmias;
not shown effective in preventing
recurrences of sustained life-threatening
ventricular arrhythmias
(4) Phenytoin: primarily used for treatment
of digoxin-induced ventricular and
supraventricular arrhythmias
(5) Moricizine: combined effect of class Ia/
Ib; may be used to treat ventricular
arrhythmias; not shown to be effective
in preventing recurrences of sustained
life-threatening ventricular arrhythmias
c) Class Ic: potent sodium channel blockers;
slow conduction with little effect on
repolarization
(1) Flecainide: may be more effective than
other class I agents in management of
Afib, flutter, and PSVT
(2) Propafenone: chemical structure is
similar to flecainides, but has type Ic
and moderate beta-adrenergic
antagonism; used similar to flecainide
2. Class II: blocks beta-adrenergic receptor sites
a) Beta-adrenergic antagonists (beta blockers):
bind at catecholamine receptor sites;
decrease automaticity and prevent reentrant arrhythmias involving the
atrioventricular (AV) node; may favorably
alter myocardial oxygen supply versus
demand and by blunting tissue response to
catecholamines
3. Class III: impact potassium channels and
prolong repolarization; prolong action potential
duration and repolarization to a greater extent
than they depress conduction velocity
a) Amiodarone: prolongs repolarization and
refractoriness in atrial and ventricular
tissue; slows sinus rate and prolongs AV
nodal conduction; alpha and beta
antagonist; can reduce systemic vascular
resistance and mean arterial blood pressure
(BP). Potent antiarrhythmic effective for a
number of arrhythmias. Prevents
recurrence of sustained Vtach or Vfib in
<60% patients; full suppression takes 46
weeks
b) Bretylium: has important interactions with
the autonomic nervous system; prolongs
action potential duration and refractoriness
in Purkinje fibers and ventricular muscle;
affects peripheral adrenergic nerve
terminals (initially causes abrupt release of
norepinephrine, then prevents further
release and reuptake); main use is in
treatment of Vtach and Vfib
c) Sotalol: patients should stay in hospital for
3 days when initiating and if dose is changed;
decreases frequency and duration of
nonsustained Vtach in <40% of patients;
prevents recurrence of sustained Vtach and
Vfib in 70% of patients; prevents recurrence
of symptomatic AFib and flutter

CHAPTER 10

V.

d) Ibutilide: for chemical cardioversion of AFib


and flutter; prolongs atrial and ventricular
refractory period; minimal effect on
conduction
4. Class IV: selectively blocks slow calcium
channels; sinoatrial (SA) and AV nodes depend
on slow channel activity; induces a
concentration-dependent depression in phase 4
depolarization and prolonged refractoriness
depressed automaticity and slowed
conduction
a) Calcium channel antagonists
(1) Verapamil: slows ventricular response
in AFib and atrial flutter, slows or
abolishes SVT using AV node for reentrant circuit
(2) Diltiazem: similar to verapamil; shorter
half-life.
b) Purinergic agonists
(1) Adenosine: inhibits sinus node
automaticity, shortens atrial refractory
period duration, depresses AV node
conduction, prolongs AV node
refractoriness; not effective in
converting atrial flutter, AFib, or Vtach
to sinus rhythm, but may allow
diagnosis
c) Digitalis glycosides
Caution: antiarrhythmics may cause
arrhythmias; agents may cause more
than one action
(1) Digoxin: control resting ventricular
rate in Afib or atrial flutter in the setting
of left ventricular dysfunction and
heart failure; may be useful as adjunctive
therapy in combination with calciumchannel blocker (CCB) or beta blocker
(BB) for rate control of chronic Afib
d) Warfarin (Coumadin)
(1) Anticoagulation: prevent potential
clotting due to abnormal blood flow,
aspirin may be used in patients at high
risk of complications from warfarin
therapy
Lipid Disorders
A. Lipoproteins
1. Clusters of lipids associated with proteins that
serve as transport vehicles for lipids in the
lymph and blood
2. Lipoproteins are distinguished by size and
density. Each contains different amounts and
kinds of lipids and proteins.
a) Chylomicrons are made by intestinal cells
and transport fatty acids from intestines to
muscle and other energy using tissues by
lipoprotein lipase.
b) Very low-density lipoproteins (VLDLs) are
made by the liver and contain large amounts
of triglyceride. They are similar to
chylomicrons because they transport fatty
acids to cells.
c) Intermediate density lipoproteins (IDLs)
result from the loss of fatty acids from VLDLs.

B.

C.

D.

E.

F.

Cardiovascular Disorders

109

They are taken up by the liver or remain in


the circulation and are converted to lowdensity lipoproteins (LDL).
d) LDL the bad cholesterol that delivers
cholesterol from liver to cells.
e) HDL the good cholesterol that are made by
the liver to scavenge or collect excess
cholesterol from cells, including
atherosclerotic plaques.
Hyperlipidemias
1. Primary hyperlipidemias: familial disease
2. Suspected in people with very high levels of
cholesterol (>300 mg/dL) or triglycerides
(>1000 mg/dL)
3. Secondary hyperlipidemias are due to other
factors such as diet, exercise, medications,
diabetes, alcohol intake, hypothyroidism,
primary biliary cirrhosis.
Laboratory tests to measure lipids
1. Total cholesterol
2. Triglycerides
3. Glycerol kinase reaction assays
Plasma lipid levels (mg/dL)
1. Total cholesterol
a) < 200 desirable
b) 200239 borderline
c) >240 high
2. LDL
a) <130 desirable (lower levels of LDL are
desirable in patients with select risk factors;
see Guidelines [F])
b) 130159 borderline
c) >160 high
3. HDL
a) <35 low
Risk factors for heart disease
1. Age (men 45 years of age; women 55 years
of age)
2. Family history of premature heart disease
a) Heart disease in male first-degree relative
<55 years
b) Heart disease in female first-degree relative
<65 years
3. Cigarette smoking
4. Hypertension (BP 140/90 mm Hg or on
antihypertensive medication)
5. Low HDL (<40 mg/dL)
6. Obesity
7. Diabetes mellitus
National Cholesterol Education Program
Adult Treatment Panel III (NCEP ATP III)
Guidelines
1. High-risk patients
a) Heart disease or heart disease risk
equivalents (10-year risk >20%)
(1) Heart disease plus
(a) Multiple risk factors
(b) Poorly controlled risk factors
(c) Multiple risk factors for metabolic
syndrome
(d) High triglycerides
(e) Low HDL
b) Goal: LDL cholesterol <100 mg/dL

110

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PHARMACOTHERAPY IN PRACTICE

Figure 10-3Algorithm for digoxin therapy for heart failure.

(Modified from Morris S, Hatcher HF, Reddy DK:


Digoxin therapy for heart failure: An update, American Family Physician, August 15, 2006. Available at: http://www.
aafp.org/afp/20060815/613.html.)

2. Moderately high risk patients


a) Two or more risk factors (10-year risk
10%20%)
b) Goal: LDL cholesterol <130 mg/dL
3. Moderate-risk patients
a) Two or more risk factors (10-year risk <10%)
b) Goal: LDL cholesterol <160 mg/dL
4. Low-risk patients
a) None or one risk factor
b) Goal: LDL cholesterol <160 mg/dL
c) If LDL cholesterol is 160 mg/dL consider
therapeutic lifestyle changes (TLC)
d) If LDL cholesterol is 190 mg/dL consider
TLC and possible drug therapy
e) If LDL cholesterol is 160189 mg/dL consider
TLC and drug therapy

G. Nondrug therapy
1. Weight control
2. Smoking cessation
3. Limit intake of saturated fat
4. Blood pressure control
H. Drug therapy
1. Hydroxymethylglutaryl-CoA (HMG-CoA)
reductase inhibitors (statins)
a) Examples
(1) Lovastatin (Mevacor), pravastatin
(Pravachol), simvastatin (Zocor),
fluvastatin (Lescol), atorvastatin
(Lipitor), rosuvastatin (Crestor)
b) Method of action
(1) Decrease LDL, triglyceride, and total
cholesterol

CHAPTER 10

(2) Inhibits HMG-CoA reductase


(3) Selective, reversible, competitive
inhibition
(4) HMG-CoA converts to mevalonic acid, a
precursor of cholesterol
c) Indications
(1) Hyperlipoproteinemia
d) Caution
(1) Patients who consume substantial
amounts of alcohol
(2) Patients with active liver disease
(3) Patients with unexplained persistent
elevations in serum aminotransferase
concentrations
(4) Contraindication: absolute liver disease,
pregnancy, lactating women, women of
childbearing age who may conceive
during therapy, hypersensitivity to
medication
e) Interactions
(1) Immunosuppressants such as
cyclosporine may increase serum
concentrations of atorvastatin, thereby
increasing the risk of myopathy.
(2) Concurrent use of fibrates with
HMG-CoA reductase inhibitors may
increase the risk of myopathy and
rhabdomyolysis.
(3) Systemic azole-derivative antifungals
(e.g., itraconazole) may decrease
the CYP 450 metabolism of HMG-CoA
reductase inhibitors. If systemic
antifungal treatment is needed, statin is
usually discontinued during the course
of antifungal treatment.
(4) Select systemic macrolides (e.g.,
erythromycin, clarithromycin) may
decrease the CYP 450 metabolism
isoenzymes of HMG-CoA reductase
inhibitors. If systemic macrolide
treatment is needed with one of these
drugs, statin is usually discontinued
during the course of the macrolide
treatment.
(5) Simvastatin, lovastatin, and atorvastatin
are major substrates of CYP 3A4.
(6) Fluvastatin is a major susbstrate of
CYP 2C9.
(7) Grapefruit juice may inhibit
metabolism of HMG-CoA reductase
inhibitors by CYP3A4; therefore high
dietary intakes of grapefruit juice should
be avoided.
f) Toxicity and side effects
(1) Increased liver function tests (LFTs)
(2) Rhabdomyolysis
(3) Headache
(4) Myopathy (myalgia and/or muscle
weakness)
(a) Risk factors
(i) Acute or chronic renal failure
(ii) Obstructive liver disease
(iii) Hypothyroidism

Cardiovascular Disorders

111

(iv) Concurrent drug therapy (e.g.,


fibrates, CYP3A4 inhibitors)
(v) Age
(vi) Sex (women more so than men)
(vii) Small body frame
(viii) Alcohol abuse
(ix) Grapefruit juice
2. Fibrates
a) Examples
(1) Clofibrate (Atromid-S), gemfibrozil
(Lopid), fenofibrate (TriCor, others)
b) Method of action
(1) Hydrolyze triacylglycerol and VLDL
(2) Causes increased removal of
triacylglycerol and VLDL from plasma
(3) Triglycerides reduced
(4) Little to no change in LDL
(5) Possible increase in HDL
(6) Greater effect seen with gemfibrozil than
clofibrate
c) Indications
(1) Hypertriglyceridemia
(2) Dyslipidemia (high triglycerides [TG],
low HDL cholesterol)
d) Caution
(1) Should be discontinued if response is
not observed within 3 months
(2) None has shown beneficial effect on
cardiovascular mortality
(3) None is considered first-line choice
(4) Patients with a history of hepatic or
renal dysfunction, peptic ulcer disease,
or gallbladder disease
(5) Contraindicated: known hypersensitivity
to medication, pregnancy, lactation
e) Interactions
(1) Fibrates may increase effects of
coumanin anticoagulants; monitor
international normalized ratio (INR)
(2) Gemfibrozil may increase the serum
concentrations of repaglinide and cause
severe hypoglycemia.
(3) Concurrent use with HMG-CoA reductase
inhibitors may increase the risk of
myopathy and rhabdomyolysis.
(4) Gemfibrozil is a strong inhibitor of
CYP 2C8, 2C9, and 2C19.
f) Toxicity and side effects
(1) Leukopenia
(2) Acute muscular syndrome (acute flu-like
syndrome)
(3) Cholelithiasis (increased cholesterol
excretion in bile)
(4) Arrhythmias
(5) Reversible increased liver function tests
(6) Nausea, abdominal pain, epigastric pain,
dyspepsia
3. Nicotinic acid
a) Examples
(1) Niaspan, Niacor
b) Method of action
(1) Inhibits lipolysis in adipose tissue,
decreasing free fatty acids

112

SECTION II

PHARMACOTHERAPY IN PRACTICE

(2) Prevents liver from forming VLDL


(3) Prevents VLDL from forming LDL, the
bad cholesterol
(4) Increases HDL, the good cholesterol
(5) May reverse some endothelial cell
dysfunction
c) Indications
(1) Hypercholesterolemia, niacin deficiency,
pellagra
d) Caution
(1) Patients with diabetes
(2) Liver dysfunction, history of jaundice
(3) Gallbladder disease
(4) Gout
(5) Peptic ulcer disease
(6) Hypersensitivity to niacin, niacinamide
e) Interactions
(1) Nicotinic acid may increase the effects of
ganglionic blocking drugs.
(2) May increase the adverse effects of HMGCoA reductase inhibitors.
f) Toxicity and side effects (not tolerated by
many patients)
(1) Flushing: especially the face and neck
(tolerance may build), may be less with
sustained-release, may pretreat with
aspirin
(2) Other: pruritus, sensation of burning,
stinging or tingling of skin, nausea,
bloating, flatulence, hunger pains,
vomiting, heartburn, diarrhea,
hypotension, dizziness, tachycardia,
syncope, headache, hyperglycemia
(3) Long-term use: rash, hyperpigmentation,
liver impairment
4. Bile acid binding resins
a) Examples
(1) Cholestyramine (Questran), colestipol
(Colestid)
b) Method of action
(1) Bind bile acids and bile salts in small
intestine
(2) Bound complex is excreted in feces
(3) Liver increases conversion of
cholesterol to bile acids
(4) Intracellular cholesterol levels decrease
(5) Increased uptake of LDL in liver
(6) May see increase in HDL
c) Indications
(1) Hypercholesterolemia (adjunct)
d) Caution
(1) GI dysfunction (constipation)
(2) Patients with phenylketonuria: flavored
Colestid granules contain aspartame,
which is converted to phenylalanine
e) Interactions
(1) Bile acid resins may bind to numerous
medications and reduce absorption;
recommend separating 1 hour before or
4 hours after other medications
f) Toxicity and side effects
(1) GI: constipation, fecal impaction,
hemorrhoids, abdominal pain, distention,

bloating, flatulence, nausea, vomiting,


diarrhea, anorexia, dyspepsia,
heartburn, biliary colic, indigestion
(tolerance may develop to flatulence and
bloating)
(2) Hyperchloremic acidosis or increased
urinary calcium excretion
5. Ezetimibe
a) Examples
(1) Zetia, also found in combination with
simvastatin (Vytorin)
b) Method of action
(1) Inhibits absorption of cholesterol at the
brush border of the small intestine
(2) Decreases transport of cholesterol to
liver
(3) Decreases total, LDL, and triglycerides
(4) Increases HDL
c) Indications
(1) Hypercholesterolemia (adjunct)
d) Caution
(1) Hepatic or renal impairment
(2) Contraindications: active liver disease
e) Interactions
(1) Concurrent use of ezetimbide with
fibrates may increase risk of
cholelithiasis
(2) Bile acid sequestrants may decrease
ezetimibe bioavailability
f) Toxicity and side effects
(1) Upper respiratory tract infection,
headache, myalgia
(2) Increased liver transaminases with HMGCoA reductase inhibitors
(3) Possible association between the use of
simvastatin and ezetimbe and increased
incidence of cancer.
6. Probucol (no longer on U.S. market, listed for
historic reference)
a) Method of action
(1) Increases fecal loss of bile acidbound
LDL
(2) Decreases synthesis of cholesterol
(3) Inhibits enteral cholesterol absorption
(4) Inhibits macrophages ingestion of
oxidized LDL
(5) Inhibits plaque formation
b) Indications
(1) Hypercholesterolemia (adjunct)
c) Caution
(1) Patients with prolonged QT interval
(2) Contraindication: pregnancy
(discontinue 6 months before
pregnancy)
d) Interactions
(1) Increased risk of toxicity when used
with medications that prolong QT
interval
e) Toxicity and side effects
(1) Prolonged QT interval (market removal
due to risk for proarrhythmia)
(2) Mild GI disturbance (tolerance should
develop)

CHAPTER 10

VI. Congestive Heart Failure


CHF represents a complex clinical syndrome characterized
by abnormalities of left ventricular function and
neurohormonal regulation. It may be caused by multiple
underlying diseases such as CHD, atherosclerosis, rheumatic
fever, cardiomyopathy, valve disorders, ventricular failure,
left or right-sided failure, hypertension, prolonged drug or
alcohol addiction, diabetes, or previous heart attack.
A. Types of heart failure
1. Left ventricular heart failure
a) Most common
b) Systolic failure: unable to contract
c) Diastolic failure: unable to relax
2. Right ventricular heart failure
a) Usually occurs after left failure
b) Less blood received causes right damage
c) Less pumping by right side
d) Venous pooling of blood in legs
B. New York Heart Association functional classification
1. Class I: Physical activity is not limited
2. Class II: Some limitation with physical activity;
comfortable at rest
3. Class III: Marked limitation with physical activity
4. Class IV: Unable to be physically active without
discomfort
C. Risk factors
1. Family history
2. Cigarette smoking
3. Obesity
4. Dyslipidemia
5. Hypertension
6. Sedentary lifestyle
7. High dietary sodium intake
D. Signs and symptoms
1. Tachycardia
2. Decreased exercise tolerance
3. Shortness of breath
a) Orthopnea (dyspnea that occurs from lying
flat)
4. Peripheral and pulmonary edema
5. Cardiomegaly
E. Goals of therapy
1. Meet oxygen requirements of the body
2. Reduce symptoms and improve quality of life
3. Reduce hospitalization
4. Reduce mortality
F. Nondrug therapy
1. Rest
2. Salt restriction
3. Fluid restriction
4. Gradual exertion programs
G. Drug therapy (Figure 10-3)
1. Cardiac glycosides (e.g., digoxin)
a) Increases force of myocardial contractility
b) Increases cardiac output
c) Increases cardiac efficiency
d) Decreases heart rate
e) Decreases cardiac size
2. Diuretics
a) Controls fluid retention and improves
symptoms rapidly
b) Should be prescribed to all patients with
evidence of fluid retention
c) Do not use alone in patients with heart failure

Cardiovascular Disorders

113

3. Drugs
a) Loop diuretics (e.g., furosemide)
b) Aldosterone antagonists with
spironolactone or eplerenone may be added
to loop diuretics to enhance diuresis and
minimize potassium loss
c) Oral metolazone, spironolactone, or
intravenous chlorothiazide can be added as
a second diuretic agent when diuretic
response is inadequate
(1) Metolazone is the drug of choice in
refractory patients with advanced renal
failure
4. Vasodilators
a) Used in patients who remain symptomatic
after administration of diuretics and digitalis
b) Useful in patients with dilated left ventricle,
normal or increase systemic blood pressure,
increased systemic vascular resistance, or
valvular regurgitation
c) Venous dilators: nitrates
d) Arterial vasodilators: hydralazine and minoxidil
5. Beta blockers (e.g., Carvedilol, metoprolol)
a) Positive actions
(1) Decreases myocardial oxygen consumption
demand by decreasing heart rate
(2) Decreases blood pressure, thereby
decreasing afterload and preload
b) Negative actions
(1) Decreases cardiac contractility
6. ACE inhibitors/ARB
a) Reduces afterload and preload; reduces
workload on the heart
b) Generates positive cardiac inotropy
c) Slows progression of left ventricular
dysfunction in CHF (ACE inhibitors)
d) Used for chronic CHF

References
Fields LE, Burt VL, Cutler JA, et al: The burden of adult
hypertension in the United States 1999 to 2000: a rising
tide, Hypertension 44:17, 2004.
Executive Summary of The Third Report of The National
Cholesterol Education Program (NCEP) Expert Panel on
Detection: Evaluation, And Treatment of High Blood
Cholesterol In Adults (Adult Treatment Panel III), JAMA.
285:24862497, 2001.
Joint National Committee on Prevention Detection,
Evaluation, and Treatment of High Blood Pressure:
The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of
High Blood Pressure, JAMA 289:25602572, 2003.
Vaughan Williams EM: Classification of anti-arrhythmic
drugs. In: Symposium on Cardiac Arrhythmias, Sandfte E,
dertalje,
Flensted-Jensen E, eds. Sweden, AB ASTRA, So
1970; 449472.

PATIENT PROFILE
Patient Initials: RM
Sex: Male
Age: 55 years
Height: 60 000

114

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PHARMACOTHERAPY IN PRACTICE

Weight: 101 kg
Race: White
Allergies: No known drug allergies (NKDA)
Chief Complaint:
RM is a 55-year old man presenting to his family physician
with increasing shortness of breath. In the past few days,
he has had more difficulty breathing, and he complains of
swelling of his ankles.
Recent History:
RM has recently been noncompliant with his reduced-salt
diet due to the start of football season at his alma mater,
including intake of salty chips and beer while tailgating
with former college buddies. He has missed a few doses of
his heart failure medications, specifically the water pill.
His shortness of breath now occurs even at rest, and to
sleep comfortably over the past several days he has
elevated his head.
Social History:
Tobacco use: None now, quit 5 years ago, before then
smoked heavily
Alcohol use: 12 drinks per week, usually in a social
setting
Medications (before admission):
Enalapril 10 mg PO twice per day (recently started,
physician is titrating dosage up to maximum
recommended for heart failure, 20 mg PO twice daily,
as tolerated)
Furosemide 20 mg PO once daily
Digoxin 0.25 mg PO qAM
Family History:
Father is alive but had a heart attack (myocardial
infarction) at age 65 years.
Mother is alive and, other than mild arthritis, is fairly
active and healthy.
Physical Exam:
Vitals: BP 139/93 mm Hg; respiratory rate 27 breathes per
minute; temperature: afebrile.
Chest: Inspiratory rales, bilateral rhonchi, decreased
breath sounds, decreased percussion
CV: Regular rate and rhythm, rate 98
Extremities: 2 pitting edema
ECG: Pattern consistent with left ventricular hypertrophy
(LVH)
CXR: Cardiomegaly, bilateral pleural effusion
Laboratories: All within normal limits.
Diagnosis: Decompensated heart failure; admit to hospital
for acute management and to maximize and stabilize
current medications.
PATIENT PROFILE QUESTIONS
1. Upon discharge from the hospital, RM should be
counseled on which of the following regarding his drug
therapy for heart failure?
I. Medications will cure heart failure.
II. Most patients with heart failure are managed on one
medication.
III. He needs to take the drug therapy for heart
failure regularly as prescribed to control
his condition.

a. I only
b. I and II only
c. III only
d. II and III only
e. All of the above
Answer: c. Adherence to medications can decrease
morbidity and mortality in patients with heart failure.
Most patients must be managed on several classes
of medications to improve health and reduces
mortality and morbidity, including angiotensinconverting enzyme (ACE) inhibitors, cardioselective
beta blockers (e.g., metoprolol or carvedilol), digoxin,
and loop diuretics. A patient with heart failure cannot
be cured with medications, but the disease can be
managed well with proper medication use.
Noncompliance with medication is a significant risk
factor and leading contributor to hospitalization in
patients with heart failure.
2. Several months later, RM is stabilized and back on his
usual medications. However, for the last few months he
has complained of a nonproductive, annoying cough.
Which of the following substitutions could be made in
his regimen to resolve this problem?
a. Spironolactone for digoxin
b. Hydrochlorothiazide for furosemide
c. Candesartan for enalapril
d. Spironolactone for furosemide
Answer: c. An angiotensin receptor blocker (ARB) is as
effective as an ACE inhibitor for heart failure.
Candesartan or valsartan are FDA-approved for this
purpose. ACE inhibitors may cause a nagging, dry cough
as a side effect. Because candesartan, an ARB, does not
break down bradykinin as an ACE inhibitor does, it does
not cause cough as a side effect.
3. Several months later RM has a worsening of heart
failure, and carvedilol is added to his current regimen.
Which of the following are contraindications to the use
of a cardioselective beta blocker?
I. Severe bradycardia
II. Second- or third- degree atrioventricular (AV) block
III. Diabetes mellitus type 2
a. I only
b. I and II
c. II and III
d. I, II, and III
Answer: b. Although beta blockers should be used
cautiously in patients with diabetes due to their ability
to mask symptoms of hypoglycemia, they are not
contraindicated.

REVIEW QUESTIONS
(Answers and Rationales on page 344.)
1. Which of the following causes increased urine output?
a. Theophylline
b. Furosemide
c. Ethacrynic acid
d. a, b, and c
e. b and c

CHAPTER 10

2. Which of the following is NOT a mechanism of


digitalis?
a. Decreased sympathetic tone
b. Enhances sympathetic responsiveness of
Sinoatrial (SA) and AV nodes
c. Enhanced vagal tone
d. Slowed AV node conduction
e. Increased CNS parasympathetic activity
3. Which of the following drugs is correctly matched to
its mechanism of action?
a. Amrinone: inhibits troponin I
b. Dopamine: inhibits troponin I
c. Digoxin: inhibits Na/K-ATPase
d. Digoxin: activates Na/K-ATPase
e. None of the above
4. Which of the following is the correct explanation for
tachycardia that occurs after nitroglycerin
ingestion?
a. Reflex sympathetic discharge
b. Decreased intracranial pressure
c. Direct positive chronotropy
d. Increased norepinephrine secretion from
intracardial nerve endings
e. None of the above
5. Which of the following is the mechanism of action
of digitalis in the correction of atrial flutter?
a. Decreased SA node firing
b. Decreased AV node refractory period
c. Increased atrial muscle conduction velocity
d. Decreased AV node conduction rate
e. a and c
6. Which of the following is true of digoxin?
a. Only available as oral tablets
b. Highly protein bound in circulation
c. Increased toxicity in renal failure
d. Incomplete gastrointestinal absorption
e. Excreted renally without significant metabolism
within 24 hours
7. A 45-year-old man receiving digitalis is found to have
premature ventricular contractions. What is the
most appropriate treatment?
a. Quinidine
b. Phenytoin
c. Digitalis Fab antibody
d. Lidocaine
e. None of the above
8. Which of the following statements about digitalis is
true?
a. It increases heart rate.
b. It decreases myocardial contractility.
c. It increases myocardial oxygen demand.
d. It decreases peripheral resistance.
e. It increases cardiac output.
9. KP is experiencing a blockage of a cerebral vessel on
the right side of her brain in the motor area. This

Cardiovascular Disorders

115

type of cerebral vascular attack (CVA) would be


expected to cause:
a. Paralysis of both legs.
b. Left side paralysis
c. Right side paralysis
d. None of the above
10. Which of the following is an uncommon effect seen
with digitalis toxicity?
a. Atrial fibrillation with rapid ventricular response
b. Premature ventricular contractions
c. Second-degree heart block
d. Third-degree heart block
e. Atrioventricular junctional escape beats
11. Which of the following may produce thiocyanate
toxicity?
a. Amrinone
b. Nitroprusside
c. Nitroglycerine
d. Milrinone
e. All of the above
12. Which of the following is NOT an effect of digitalis?
a. Prolonged function AV node refractory period
b. Increased vagal tone
c. Decreased Purkinje fiber effective refractory
period
d. Decreased AV node conduction velocity
e. Decreased myocardial contractility
13. Which of the following may cause orthostatic
hypotension?
a. Metaraminol
b. Tetrahydrozoline
c. Amyl nitrite
d. Reserpine
e. Phenylephrine
14. Which of the following is most similar structurally to
digitalis?
a. Steroids
b. Catecholamines
c. Salicylates
d. Phenothiazines
e. Nitrofurantoin
15. Which of the following is NOT an effect of nitrate
ingestion?
a. Decreased preload
b. Decreased systolic blood pressure
c. Increased ejection fraction
d. Decreased ventricular size
e. Increased heart rate
16. Which of the following acts directly on the kidneys
to promote diuresis?
a. Dobutamine
b. Dopamine
c. Epinephrine
d. Isoproterenol
e. Norepinephrine

116

SECTION II

PHARMACOTHERAPY IN PRACTICE

17. Nitroglycerin decreases myocardial oxygen demand


via decreases in:
a. intramyocardial tension
b. sulfhydryl bonding
c. blood pressure
d. heart rate
e. coronary vascular resistance
18. Which of the following drugs would be contraindicated
for someone with a potassium level of 5.2?
a. Warfarin
b. Hydocholorathiazide
c. Furosemide
d. Spironalactone
19. Which of the following is the correct mechanism by
which digitalis decreases heart rate?
a. Increased AV node conduction
b. Atropine-like effects on the AV node
c. Blockage of carotid baroreceptors
d. Stimulation of medullary vagal center
e. All of the above
20. Digoxin:
a. is more extensively cleared by the liver than
digitoxin.
b. is more poorly absorbed orally than digitoxin.
c. is more protein bound than digitoxin.
d. has a longer half-life than digitoxin.
e. All of the above
21. Digitalis:
a. decreases ventricular rate in atrial fibrillation.
b. decreases atrial rate in sinus tachycardia.
c. decreases atrial rate in atrial fibrillation.
d. enhances AV node conduction.
e. decreases ventricular automaticity.
22. Which of the following statements about digitalisassociated emesis is true?
a. It is due to Na/K-ATPase inhibition within the
stomach.
b. It is due to stimulation of chemoreceptor trigger
zones.
c. It is only seen with oral administration.
d. It is only seen with rapid IV administration.
e. It is never severe.
23. Digitalis:
a. increases heart rate.
b. prevents diastolic dysfunction.
c. can percipitate arrhythmias.
d. increases oxygen consumption in failing hearts.
e. None of the above
24. Which of the following statements regarding
adenosine is true?
a. It increases sinus node rate.
b. It increases AV conduction.
c. It causes transient postconversion
arrhythmias.
d. It is extensively metabolized in the liver.
e. It causes coronary vasoconstriction.

25. GPs blood pressure is 172/104. This is considered


to be:
a. Prehypertension
b. Stage I hypertension
c. Stage II hypertension
d. Organ dysfunction
26. Hydochlorathiazide is used to treat hypertension.
The antihypertensive effect of this drug is caused by
which of the following?
I. Inhibition of the angiotension converting enzyme
II. Calcium channel blockade
III. Diuresis and vasodilatation
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

27. Which of the following is an incorrect administration


of epinephrine for the treatment ventricular
fibrillation?
a. 2.5 mg diluted with saline to a total of 10 mL via
endotracheal tube
b. 1 mg IV push, then 3 mg IV push, then 5 mg IV
push, with 3-minute intervals
c. 0.1 mg/kg IV push every 35 minutes
d. 0.1 mg IV push every 35 minutes
e. 1 mg IV push every 35 minutes
28. A patient is started on heparin (5000 U bolus
followed by 1000 U/h) for the treatment of deep vein
thrombosis. When is the earliest time that a blood
sample can be drawn to measure aPTT?
a. 24 hours
b. 12 hours
c. 6 hours
d. 4 hours
e. 2 hours
29. Which of the following is a direct-acting plasminogen?
a. Urokinase
b. Streptokinase
c. Epsilon-aminocaproic acid
d. Anistreplase
e. Heparin
30. Which of the following statements about warfarin is
true?
a. It inhibits vitamin K epoxide reductase.
b. It prevents carboxylation of factors II, VII, IX,
and X.
c. It competitively inhibits hepatic liver synthesis
of clotting factors.
d. a and b
e. b and c
31. Which of the following increases the activity of
warfarin?
a. Aspirin
b. Ranitidine
c. Trimethoprim-sulfamethoxazole

CHAPTER 10

d.
e.

Rifampin
a and c

32. Which of the following statement about mini-doses


of heparin is true?
a. It is useful as prophylactive therapy.
b. It inhibits factor X activation.
c. Factor X is much more sensitive to heparin than
other serine proteases.
d. All of the above
e. None of the above
33. Which of the following statements about fibrinolytic
agents is true?
a. It increases mortality in acute myocardial
infarction.
b. Urokinase directly activates plasminogen.
c. Streptokinase directly activates plasminogen.
d. TPA may cause rash.
e. TPA may cause the development of antibodies.
34. Which of the following drugs taken for heart failure
have been proved to decrease mortality according
to clinical study?
I. Carvedilol
II. Lisinopril
III. Digoxin
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

35. Which of the following is NOT an adverse effect of


amiodarone?
a. Pulmonary fibrosis
b. Hyperthyroidism
c. Optic neuropathy
d. Thrombocytopenia
e. Elevated liver function tests
36. A 35-year-old obese woman presents to the
emergency department with complaints of acute
shortness of breath, fever, and confusion. Her left
lower calf is swollen, and the treating physician
suspected pulmonary embolism. Which of the
following is the most appropriate laboratory
screening test?
a. D-dimer
b. Prothrombin time
c. Erythrocyte sedimentation rate
d. International normalized ratio (INR)
e. Factor VII activity
37. Warfarin acts by:
a. inhibiting synthesis of calcium-dependent
clotting factors.
b. decreasing absorption of vitamin K.
c. degrading clotting factors in the peripheral
circulation.
d. binding clotting factors.
e. inhibiting hepatic vitamin B12 synthesis and
storage.

Cardiovascular Disorders

117

38. Which of the following is the appropriate goal of INR


in a patient with atrial fibrillation and mitral valve
disease?
a. 4.5
b. 3.5
c. 2.5
d. 1.5
e. 0.5
39. Which of the following cardiac arrythmias can be
due to a re-entry mechanism?
a. Atrial fibrillation
b. Atrial flutter
c. Ventricular fibrillation
d. Ventricular tachycardia
e. All of the above
40. The most life threatening adverse effect of taking a
HMG coenzyme A reductase inhibitor (Statins) is:
a. Angioedema
b. Renal failure
c. Myalgia
d. Rhabdomyolysis
41. Which of the following factors has NOT been
implicated in the pathogenesis of hypertension?
a. Increased sympathomimetic activity
b. Mineralocorticoid excess
c. Genetic factors
d. Reduced renal function
e. All of the above have been implicated in
pathogenesis of HTN
42. Which of the following is a risk factor for the
development of hypertension during childhood?
a. African American race
b. Anorexia
c. Elevated birth weight
d. Increased environmental exposure
e. Female sex
43. According to the AHA/ACC approach to the
classification of chronic heart failure, how is stage A
(Class I) defined?
a. Unable to carry out physical activity without
discomfort
b. Advanced structural heart disease and marked
symptoms
c. Symptomatic at rest
d. Asymptomatic
e. High risk of developing heart failure but with no
identified structural or functional abnormalities
44. Which of the following drugs may produce excessive
hair growth?
a. Zyprexa
b. Loniten
c. Risperidal
d. Lasix
e. All of the above
45. Which of the following adverse effects occur(s) with
ACE inhibitors?
a. Neutropenia

118

SECTION II

b.
c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Hyperkalemia
Orthostatic hypotension
a and c
a, b, and c

46. Congestive heart failure (CHF) is diagnosed in an


elderly patient. Which of the following medications
should be avoided?
a. Nitrostat
b. Catapres
c. Verelan
d. Diuril
e. All of these drugs are safe for elderly patients
with CHF
47. A patient complains of intestinal side effects
associated with the recent addition of verapamil
(Verelan) to her medication profile. Which of the
following would you likely recommend for alleviating
of these side effects?
a. Cessation of Verelan therapy
b. Counsel the patient that side effects are
untreatable
c. Maalox extra strength tablets
d. Pericolace
e. Alternagel
48. Digitalis toxicity is associated with a
I. Decrease in serum concentration of K
II. Decrease in serum concentration of Mg2
III. Increase in serum concentration of Ca2
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

49. A cardiologist calls a pharmacist to inquire about


the use of nesiritide in patients with congestive
heart failure. Which of the following is a
contraindication for nesiritide use?
a. Systolic blood pressure less than 90 mm Hg
b. Concurrent ACE inhibitor use
c. Previous treatment with streptokinase
d. Iodine allergy
e. None of the above

c.
d.
e.

Fluid retention
a and b
a and c

52. The most accurate measure of cardiac output is:


a. Systolic blood pressure
b. Diastolic blood pressure
c. Heart rate
d. Urine output
53. What class of antiarrhythmic agent is diltiazem, and
what is an appropriate indication for diltiazem
treatment?
a. Class IV, supraventricular tachycardia
b. Class IV, atrial fibrillation
c. Class I, supraventricular tachycardia
d. Class I, atrial fibrillation
e. a and b
54. Which of the following antihypertensive medications
is most appropriate for use in a patient with asthma
with poor compliance?
a. Acebutolol
b. Propranolol
c. Esmolol
d. a or b
e. a or c
55. Chronic hypertension negatively affects what organ(s)?
a. Lungs
b. Brain
c. Eyes
d. a and b
e. b and c
56. Which of the following should be monitored in
patients taking thiazide diuretics?
a. Potassium and glucose
b. Potassium, glucose, and uric acid
c. Potassium and uric acid
d. Glucose and uric acid
e. Uric acid
57. Preload is best assessed by:
a. Peripheral edema
b. Jugular veins
c. Blood pressure
d. Urine output

50. A patient with long-standing congestive heart failure


complains of lower leg swelling and nighttime
breathing difficulty. Which of the following drugs
would be most appropriate?
a. Digoxin
b. Metolazone
c. Captopril
d. a and b
e. a and c

58. Which of the following is the correct mechanism of


action of digitalis in patients with congestive heart
failure?
a. Increased heart rate
b. Increased stroke volume
c. Decreased blood pressure
d. Decreased venous return
e. Decreased peripheral resistance

51. Which of the following adverse effects may occur in


patients treated concomitantly with propranolol and
diltiazem?
a. Decreased heart rate
b. Decreased cardiac output

59. Congestive heart failure is diagnosed in a 75-year-old


woman. Which of the following medications would
improve this patients symptoms by decreasing
preload and afterload?
a. Nitroprusside

CHAPTER 10

b.
c.
d.
e.

Prazosin
Felodipine
Hydralazine
Isosorbide dinitrate

60. Digitalis toxicity can be managed with which of the


following?
a. Lidocaine
b. Phenytoin
c. Potassium
d. Cholestyramine
e. None of the above
61. Right-sided heart failure may result in:
I. Ascites
II. Peripheral edema
III. Pulmonary edema
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

62. A 55-year-old woman with breast cancer develops a


deep vein thrombosis. She is treated with
enoxaparin and warfarin. How long should
enoxaparin therapy be continued?
a. 7 days
b. 1 month
c. 36 months
d. 912 months
e. Indefinitely
63. A 60-year-old man is taken to the emergency
department by his wife after taking a full bottle of
0.25 mg digoxin tablets in a suicide attempt. He has a
pulse of 45 beats per minute; electrocardiogram
shows third-degree heart block. Which of the
following is the first therapy that should be initiated?
a. Potassium
b. Lidocaine
c. Digoxin immune Fab
d. Phenytoin
e. Sodium bicarbonate
64. Which of the following patients does NOT require
dose adjustment of enoxaparin?
a. 80-year-old woman with low body weight
b. 80-year-old woman with renal insufficiency
c. 30-year-old pregnant female with mechanical
prosthetic heart valve
d. 30-year-old anorexic woman
e. 50-year-old man with prostatic hypertrophy and
hypertension
65. Digoxin is classified as a(an):
a. glycoside
b. parasympathomimetic
c. calcium channel blocker
d. potassium channel blocker
e. angiotensin receptor blocker

Cardiovascular Disorders

119

66. Lovenox:
a. requires monitoring of laboratory coagulation
parameters when given presurgically in
recommended doses.
b. is administered in doses of 300 mg q12h
intravenously.
c. is administered in doses of 300 mg q12h
intramuscularly.
d. is administered in doses of 300 mg q12h
subcutaneously.
e. is used for deep vein thrombosis
prophylaxis.
67. Which of the following drugs may result in increased
INR in patients on warfarin?
a. Digoxin
b. Cefotetan
c. Pantoprazole
d. a or b
e. b or c
68. JK is a diabetic patient who began atenolol
(Tenormin) this morning. What lab value should be
monitored?
a. Glucose
b. Calcium
c. Magnesium
d. Potassium
69. All of the following statements about furosemide are
true EXCEPT:
a. it is useful in the treatment of ascites.
b. it may result in hypouricemia.
c. it may result in tinnitus.
d. it acts at the thick ascending loop of Henle.
e. it may result in hypocalcemia.
70. Which of the following statements about
spironolactone is FALSE?
a. It may cause gynecomastia.
b. It may cause hypokalemia.
c. It may cause urine alkalinization.
d. It may cause menstrual irregularities.
e. It may cause hyponatremia.
71. Diazoxide is most similar in structure to which of the
following agents?
a. Chlorothiazide
b. Furosemide
c. Spironolactone
d. Acetazolamide
e. Mannitol
72. Which of the following is NOT a potential side effect
of enalapril?
a. Agranulocytosis
b. Acute renal failure
c. Reflex hypertension
d. Alopecia
e. Abnormal taste

120

SECTION II

PHARMACOTHERAPY IN PRACTICE

73. Cardiac glycosides may cause all of the following


EXCEPT:
a. anorexia.
b. vomiting.
c. atrioventriuclar block.
d. confusion.
e. red/blue vision.
74. Beta-adrenergic agents may cause which of the
following adverse events?
a. Hypotension
b. Congestive heart failure
c. Increased airway resistance
d. Bradycardia
e. All of the above
75. Which of the following statements about warfarin is
true?
a. Normal daily dosage is 210 mcg/d.
b. It is not useful in the management of cardiac
valve replacement.
c. It may cause mania.
d. It may cause hematuria.
e. It is safe to use in pregnancy.
76. Which of the following factors are responsible for
the longer duration of digitoxin compared to
digoxin?
a. Increased protein binding
b. Decreased polarity
c. Increased tubular reabsorption
d. All of the above
e. None of the above
77. RO is receiving furosemide (Lasix) for fluid
retention. Which of the following is a complication of
the therapy?
a. Hyperkalemia
b. Urinary incontinence
c. Hypercalcemia
d. Ototoxicity
e. Hypermagnesemia
78. A pharmacist is counseling a new patient in the
anticoagulant clinic who is beginning warfarin therapy.
Which of the following should the patient avoid?
a. Red wine
b. Vitamin K
c. Vitamin E
d. High-cholesterol foods
e. All of the above
79. Which of the following should NOT be treated with
cardiac glycosides?
a. Congestive heart failure
b. Ventricular tachycardia
c. Atrial fibrillation
d. Paroxysmal atrial tachycardia
e. Glycosides can be used in all of the above
80. Which of the following is safe to use in patients with
hypokalemia?
a. Midamor

b.
c.
d.
e.

Lasix
Zaroxolyn
Hygroton
Diuril

81. Which of the following is NOT safe to take in


combination with digoxin?
a. Tigecycline
b. Etanercept
c. Apreptate
d. Fosapreptate
e. Amiodarone
82. Which of the following statements about clonidine is
true?
a. It is an alpha-2 antagonist.
b. It may cause drowsiness.
c. It does not require dose adjustment for renal
insufficiency.
d. a and b
e. b and c
83. Which of the following is the mechanism of action of
clonidine?
a. Alpha-2 antagonist
b. Alpha-2 agonist
c. Beta-1 agonist
d. Beta-1 agonist
e. Mixed alpha-1 and alpha-2 antagonist
84. Which of the following statements about furosemide
(Lasix) is FALSE?
a. It is available for intramuscular
administration.
b. It may cause aortitis.
c. It may cause vertigo.
d. It may be used for the treatment of edema.
e. It is minimally protein bound in circulation.
85. Which of the following statements about heparin is
true?
a. It may cause rebound hyperlipidemia.
b. It may cause hyperkalemia.
c. It may cause priapism.
d. a and b
e. a, b, and c
86. Which of the following are angiotensin II receptor
blockers?
a. Cozaar
b. Diovan
c. Avapro
d. a and b
e. a, b, and c
87. Which of the following does NOT carry a risk of
myositis?
a. Gemfibrozil
b. Colestipol
c. Lovastatin
d. Simvastatin
e. Pravastatin

CHAPTER 10

Cardiovascular Disorders

121

88. Which of the following has strong anticholinergic


effects?
a. Disopyramide
b. Procainamide
c. Flecanide
d. Tocainide
e. Quinidine

96. Of the following medications, which may cause rash,


cough, and proteinuria?
a. Terazosin
b. Penbutolol
c. Nitroprusside
d. Methyldopa
e. Ramipril

89. Which of the following has the greatest risk of


inducing torsades de pointes?
a. Quinidine
b. Flecainide
c. Diltiazem
d. Lidocaine
e. Amiodarone

97. Methyldopa may cause which of the following?


a. Fever
b. Postural hypotension
c. Positive Coombs test
d. All of the above
e. None of the above

90. Which drug acts on the atrioventricular node to


delay calcium channel depolarization?
a. Verapamil
b. Nifedipine
c. Quinidine
d. Bretylium
e. Lidocaine
91. Bretylium:
a. is a class II antiarrhythmic.
b. is useful in the treatment of ventricular
tachycardia.
c. is only available for intramuscular injection.
d. may cause hypertension.
e. may cause tachycardia.
92. Which of the following is a potential problem with
amiodarone therapy?
a. It may cause pulmonary fibrosis.
b. It may cause thyroid disease.
c. It may require multiple daily doses.
d. a and b
e. a, b, and c
93. Which of the following antihypertensive drug may
cause headache, postural hypotension, and reflex
tachycardia?
a. Hydralazine
b. Prazosin
c. Captopril
d. Methyldopa
e. Guanethidine
94. Which of the following is a potential side effect of
nitroprusside therapy?
a. Thiocyanate intoxication
b. Convulsions
c. Hypotension
d. All of the above
e. None of the above
95. Which of the following is a potential side effect of
penbutolol?
a. Bronchospasm
b. Cardiac decompensation
c. Bradycardia
d. All of the above
e. None of the above

98. Which drug has sympathomimetic activity?


a. Pindolol
b. Nadolol
c. Labetalol
d. Esmolol
e. Bisoprolol
99. Which drug is an alpha-adrenergic receptor
blocker?
a. Pindolol
b. Nadolol
c. Labetalol
d. Esmolol
e. Bisoprolol
100. Which drug has the shortest duration of action?
a. Pindolol
b. Nadolol
c. Labetalol
d. Esmolol
e. Bisoprolol
101. Which drug is a nonselective blocker with a
prolonged duration of action?
a. Pindolol
b. Nadolol
c. Labetalol
d. Esmolol
e. Bisoprolol
102. Which drug is the most cardioselective?
a. Pindolol
b. Nadolol
c. Labetalol
d. Esmolol
e. Bisoprolol
103. Which of the following statements about clopidogrel
is true?
a. It has a higher risk of bleeding than aspirin.
b. It is an isomer of ticlopidine.
c. It may cause thrombocytopenia.
d. It is a glycoprotein IIb/IIIA inhibitor.
e. All of the above
104. Which of the following produces prolonged platelet
inhibition?
a. Aspirin
b. Corticosteroids

122

SECTION II

c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Ibuprofen
Penicillamine
Auranofin

105. What is normal serum concentration of potassium?


a. 1 mEq/L
b. 12 mEq/L
c. 3.55 mEq/L
d. 10 mEq/L
e. 35 mEq/L

c.
d.
e.

Pioglitazone
Losartan
Captopril

112. Which of the following side effects is associated with


hydrochlorothiazide?
a. Photosensitivity
b. Hypokalemia
c. Hypotension
d. Anorexia
e. All of the above

106. Hypertensive crisis is defined as a diastolic blood


pressure greater than 120 mmHg. What is the best
medication for initial treatment of hypertensive
crisis?
a. Nnitroprusside
b. Hydralazine
c. Amlodipine
d. Esmolol
e. Digoxin

113. VH is a 68-year old female with congestive heart


failure. She is being treated with enalapril. Which of
the following changes in plasma renin and
angiotensin II levels would occur?
a. Decrease; decrease
b. Increase; decrease
c. Increase, increase
d. Increase, no change

107. Chest pain that is NOT relieved by rest and


nitroglycerin is referred to as which of the
following?
a. Variant angina
b. Stable angina
c. Unstable angina
d. Prinzmetals angina

114. The antiarrhythmic agent recommended for treating


life threatening ventricular fibrillation in a 57-year
old man is?
a. Amiodarone
b. Esmolol
c. Quinidine
d. Adenosine

108. Lovastatin works by inhibition of?


a. Lipolysis of TAGs in adipose tissue
b. HMG CoA reductase, the rate-limiting step of
cholesterol synthesis
c. 7-a hydroxylase, the rate limiting step of bile
salt synthesis
d. Release of cholesterol in lysozomes

115. Familial hypercholesterolemia results from defects in?


a. HMG CoA reductase
b. Chylomicron assembly
c. Hormone-sensitive lipase
d. LDL receptors

109. Calcium channel blockers have which of the


following functions?
a. Increase cerebral oxygenation
b. Increase vascular tone
c. Increase velocity of AV conduction
d. Decrease cardiac oxygen consumption

116. MS is a 60-year old obese woman with type


2 diabetes, hypertension, and renal disease. She is
being treated with a drug that blocks both alphaand beta-receptors. This drug is likely:
a. Acebutolol
b. Carvedilol
c. Doxazosin
d. Pindolol

110. WP is a 64-year old man with chronic, drug-resistant


hypertension that is being treated with furosemide,
metoprolol, and a drug that produces a vasodilatory
effect on arterial smooth muscles, causing a
reduction in blood pressure in peripheral resistance.
What is most likely the third drug?
a. Nnitroprusside
b. Minoxidil
c. Guanethidine
d. Clonidine

117. LB is a 53-year old female with very high


triglycerides and VLDL levels. She is given a drug
that decreases hepatic production of apolipoprotein
CIII via activation of peroxisome proliferator
activator receptors (PPARs) and induces lipoprotein
lipase. The drug is likely:
a. Fenofibrate
b. Colestipol
c. Ezetimibe
d. Lovastatin

111. MH is a 42-year old female with type 1 diabetes that


is being treated with various drugs including a drug
for the prevention of proteinuria associated with
diabetic nephropathy. After she began this drug, the
patient developed a dry cough. The cough most
likely caused by which of the following?
a. Aamiloride
b. Furosemide

118. Which of the following agents are effective in


treating congestive heart failure (CHF)?
I. Digoxin
II. Hydralazine
III. Hydrochlorothiazide
a.
b.

I only
III only

CHAPTER 10

c.
d.
e.

I and II only
II and III only
I, II and III

119. JW is a 52 year old patient receiving simvastatin for


hypercholesterolemia, but is inadequately
controlled. The addition of which of the following
agents will increase the risk of myopathy?
a. Psyllium
b. Colestipol
c. Cholestyramine
d. Gemfibrozil
e. None of the above
120. Which of the following tests is important when
determining the optimal drug therapy for a patient
newly diagnosed with heart failure?
a. Chest x-ray
b. Electrocardiogram (ECG)
c. Echocardiogram (ECHO)
d. Renal arteriography
121. Which of the following drugs has been shown to
reduce mortality in patients with heart failure?
a. Enalapril
b. Digoxin
c. Furosemide
d. Amlodipine
e. None of the above
122. NC is a 57-year old female who has diabetes and
hypertension. She also takes levothyroxine. NC
develops a cold with nasal congestion and asks you
which product to use. Which of the following is the
safest to recommend to this patient with nasal
congestion?
a. Saline nasal spray
b. Phenylephrine nasal spray
c. Pseudoephedrine
d. Chlorpheniramine
123. How does trimethoprim-sulfamethoxazole affect INR
values in patients taking warfarin?
a. No effect on INR
b. Increase in INR
c. Decrease in INR
d. Increase in INR with high-dose trimethoprimsulfamethoxazole, and decrease in INR with lowdose trimethoprim-sulfamethoxazole
e. Decrease in INR with high-dose trimethoprimsulfamethoxazole, and increase in INR with lowdose trimethoprim-sulfamethoxazole
124. A 32-year-old woman is taking warfarin for a recent
deep vein thrombosis. At her regular check-up, her
INR is found to be 9.0. She reports no history of
bleeding or bruising. Which of the following is the
most appropriate treatment?
a. Cessation of warfarin
b. Oral vitamin K
c. Subcutaneous vitamin K
d. a and b
e. a and c

Cardiovascular Disorders

123

125. Warfarin:
a. inhibits vitamin K absorption.
b. has a duration of action of 25 days.
c. is less than 50% protein bound in
circulation.
d. has an onset of action of 25 hours
e. is primarily metabolized by CYP2D6.
126. Which of the following statements about class IA
antiarrhythmic medications is true?
a. They prolong PR and QT intervals.
b. They reduce Purkinje fiber automaticity.
c. The decrease the rate of rise and amplitude of
phase 0 depolarization.
d. a and b
e. a, b, and c
127. All of the following are class IB antiarrhythmic
agents EXCEPT:
a. mexiletine
b. lidocaine
c. phenytoin
d. tocainide
e. All of the above are class IB antiarrhythmic
agents
128. Which of the following drugs will NOT increase
the effective refractory period of the AV node
in the treatment of supraventricular
tachycardia?
a. Propranolol
b. Tocainide
c. Digoxin
d. Verapamil
e. All of the above will increase the AV refractory
period
129. Adverse effects of amiodarone include all of the
following EXCEPT:
a. photosensitivity.
b. pseudocyanosis.
c. pneumonitis.
d. parotitis.
e. All of the above may occur with
amiodarone
130. Which of the following is an effect of class IC
antiarrhythmic agents?
a. Phase 0 depolarization depression
b. Inhibition of calcium transport during action
potential plateau
c. Inhibition of sodium transport during phase 0
depolarization
d. a and b
e. a and c
131. Adverse effects of disopyramide include all of the
following EXCEPT:
a. lupus
b. urinary retention
c. blurry vision
d. constipation
e. Disopyramide may cause any of the above

124

SECTION II

PHARMACOTHERAPY IN PRACTICE

132. Which of the following is NOT a type I


antiarrhythmic agent?
a. Propranolol
b. Lidocaine
c. Procainamide
d. Quinidine
e. Phenytoin
133. Which of the following is an effect of quinidine?
a. Increased QRS and PR intervals
b. Increased QRS and QT intervals
c. Increased QRS, PR, and QT intervals
d. Increased PR and QT intervals
e. Increased QT interval
134. Adverse effects of quinidine include all of the
following EXCEPT:
a. Dry mouth
b. Nausea
c. Tinnitus
d. Torsades de pointes
e. Headache
135. Which of the following has a mechanism of action
and electrophysiologic effects most similar to
procainamide?
a. Lidocaine
b. Bretylium
c. Quinidine
d. Phenytoin
e. Propranolol
136. Which of the following is NOT an effect of
quinidine?
a. Positive chronotropy
b. Prolongation of effective refractory period
c. Decreased conduction velocity
d. Peripheral vasodilation
137. Which of the following should NOT be used in a
patient with complete heart block?
a. Atropine
b. Quinidine
c. Isoproterenol
d. Prednisone
e. Hydrochlorothiazide
138. Which of the following is an effect of
procainamide?
a. Improved myocyte membrane
responsiveness
b. Decreased effective refractory period
c. Decreased ectopic myocardial automaticity
d. a and b
e. a and c
139. Decreased numbers of beta-adrenergic receptors
may be due to:
a. guanethidine.
b. alcohol withdrawal.
c. beta agonists.
d. propranolol.
e. None of the above

140. A 45-year-old man experiences an acute myocardial


infarction. The following day he is being treated
with an intravenous antiarrhythmic agent to
prevent multifocal premature ventricular contractions
when he experiences a seizure. What is the most likely
cause of the seizure?
a. Ventricular asystole
b. Systemic hypotension
c. Lidocaine toxicity
d. Ventricular tachycardia
e. Cardiac embolization
141. Which of the following is NOT a class III
antiarrhythmic agent?
a. Quinidine
b. Propafenone
c. Flecainide
d. Bretylium
e. a, b, and c
142. Which of the following is first-line treatment for
ventricular fibrillation that does not respond to
defibrillation or epinephrine?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide
143. Which of the following is the appropriate treatment
for supraventricular tachycardia refractory to vagal
maneuvers?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide
144. Which of the following causes an initial release of
norepinephrine resulting in transient hypertension
followed by hypotension?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide
145. Which of the following may cause hyper- or
hypothyroidism due to iodine content?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide
146. Which of the following is highly protein bound in
circulation, has a large volume of distribution, and
has a long half-life (>20 days)?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide

CHAPTER 10

Cardiovascular Disorders

125

147. Which of the following is a class IB antiarrhythmic


agent with rapid association and dissociation with
sodium channels?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide

154. Which of the following is a cardioselective beta


blocker that is only administered intravenously and
has a short elimination half-life?
a. Esmolol
b. Propranolol
c. Acebutolol
d. Sotalol
e. Butorphanol

148. Which of the following is a class IC antiarrhythmic


agent with a strong affinity and slow dissociation
from sodium channels?
a. Amiodarone
b. Lidocaine
c. Bretylium
d. Adenosine
e. Flecainide

155. Which of the following statements


concerning calcium channel blockers is
FALSE?
a. They can be used to slow ventricular rate in
atrial fibrillation.
b. Verapamil, diltiazem, and nifedipine
have equivalent antiarrhythmic actions.
c. They decrease inward calcium current, causing
decreased spontaneous phase 4 depolarization
of Purkinje cells.
d. They slow AV node conduction velocity.
e. They increase the functional refractory period
of the AV node.

149. All of the following statements about propafenone


are true EXCEPT:
a. it is a class III antiarrhythmic agent.
b. it has increased QRS duration.
c. it slows action potential.
d. it has beta-blocking activity.
e. it blocks sodium channels.
150. All of the following statements about sotalol are true
EXCEPT:
a. it increases effective refractory period.
b. it causes bradycardia.
c. it prolongs action potential duration and
effective refractory period via blockage of
sodium channels.
d. it blocks potassium channels.
e. it prolongs repolarization.
151. Which of the following is a nonselective beta
blocker with quinidine-like effects on cellular
membranes?
a. Esmolol
b. Propranolol
c. Acebutolol
d. Sotalol
e. Butorphanol
152. Which of the following is a cardioselective beta
blocker that is only administered orally and has
sympathomimetic activity?
a. Esmolol
b. Propranolol
c. Acebutolol
d. Sotalol
e. Butorphanol
153. Which of the following is a nonselective beta blocker
that prolongs action potential duration via blockage
of potassium transport?
a. Esmolol
b. Propranolol
c. Acebutolol
d. Sotalol
e. Butorphanol

156. Which of the following is most closely related to


diazoxide?
a. Nitrates
b. Dopamine antagonists
c. Thiazides
d. Nitrofurantoin
e. Sulfonamides
157. Which of the following may cause hyperuricemia
and acute gout?
a. Chlorothiazide
b. Phenytoin
c. Salicylates
d. Spironolactone
e. a and c
158. Which of the following is a potential side effect of
reserpine?
a. Diarrhea
b. Bradycardia
c. Postural hypotension
d. a and c
e. a, b, and c
159. Which of the following is NOT a potential side effect
of propranolol?
a. Angina
b. Hypotension
c. Tachycardia
d. Syncope
e. Raynaud syndrome
160. Which of the following is NOT a side effect of
methyldopa?
a. Nephrotic syndrome
b. Fever
c. Hemolytic anemia
d. Positive Coombs test
e. Diarrhea

126

SECTION II

PHARMACOTHERAPY IN PRACTICE

161. Which of the following is NOT a side effect of


hydralazine?
a. Depression
b. Disorientation
c. Bradycardia
d. Impotence
e. Muscle cramps

169. Which of the following agents acts predominately at


the arteriolar level?
a. Gliazoxide
b. Minoxidil
c. Hydralazine
d. a and b
e. a, b, and c

162. Which of the following may cause somnolence?


a. Guanethidine
b. Methyldopa
c. Hydralazine
d. a and b
e. b and c

170. What is the onset of action of IV nitroprusside?


a. 24 hours
b. 12 hours
c. 6 hours
d. 2 hours
e. Seconds

163. Which of the following may cause salt and water


retention?
a. Guanethidine
b. Methyldopa
c. Clonidine
d. a and b
e. a, b, and c

171. In which of the following conditions is methyldopa


contraindicated?
a. Renal insufficiency
b. Hepatic disease
c. Asthma
d. Coronary insufficiency
e. Depression

164. Which of the following is a potential side effect of


clonidine?
a. Rebound hypertension
b. Lupus
c. Anaphylaxis
d. Ventricular fibrillation
e. Nephrotoxicity

172. In which of the following conditions is hydralazine


contraindicated?
a. Renal insufficiency
b. Hepatic disease
c. Asthma
d. Coronary insufficiency
e. Depression

165. Which of the following is NOT an effect of


propranolol?
a. Negative chronotropy
b. Negative inotropy
c. Decreased plasma renin
d. Hyperglycemia
e. Bronchoconstriction

173. In which of the following conditions is reserpine


contraindicated?
a. Renal insufficiency
b. Hepatic disease
c. Asthma
d. Coronary insufficiency
e. Depression

166. Which of the following will increase cardiac output?


a. Hydralazine
b. Guanethidine
c. Methyldopa
d. Reserpine
e. Chlorothiazide

174. Which of the following may cause decreased tissue


concentration of norepinephrine?
a. Alpha-methyl-p-tyrosine
b. Reserpine
c. Guanethidine
d. a and b
e. b and c

167. Which of the following acts by lowering sympathetic


tone of the vasculature?
a. Reserpine
b. Methyldopa
c. Trimethaphan
d. Diazoxide
e. Phenoxybenzamine
168. Which of the following are most useful for the
long-term management of essential
hypertension?
a. Osmotic diuretics
b. Xanthine diuretics
c. Mercurial diuretics
d. Thiazide diuretics
e. Carbonic anhydrase inhibitors

175. In which of the following conditions is propranolol


contraindicated?
a. Renal insufficiency
b. Hepatic disease
c. Asthma
d. Coronary insufficiency
e. Depression
176. Which of the following is NOT a side effect of
guanethidine?
a. Constipation
b. Bradycardia
c. Retrograde ejaculation
d. Orthostatic hypotension
e. Dry mouth

CHAPTER 10

177. For which of the following is propranolol safe to use?


a. Congestive heart failure
b. Asthma
c. Migraine prophylaxis
d. Third-degree heart block
e. Sinus bradycardia
178. A patient taking hydralazine and
hydrochlorothiazide complains of headaches. His
blood pressure is 125/75. What is the likely cause of
his headaches?
a. Hypotension
b. Hypokalemia
c. Hydralazine
d. Stress
e. Agranulocytosis
179. Which of the following statements about clonidine
is/are true?
a. It can be stopped safely for an outpatient
operation.
b. It should not be stopped abruptly.
c. It may cause rebound hypertension.
d. b and c
e. a, b, and c
180. Which of the following medications shows reduced
efficacy when combined with tricyclic
antidepressants?
a. Guanethidine
b. Clonidine
c. Hydralazine
d. a and b
e. b and c
181. Which of the following may cause tachycardia?
a. Clonidine
b. Diazoxide
c. Hydralazine
d. a and b
e. b and c
182. Which of the following statements about sodium
nitroprusside is INCORRECT?
a. It should be given via rapid IV push.
b. Thiocyanate is a metabolite.
c. It is an arterial and venous dilator.
d. a and b
e. a and c
183. Which of the following may occur with chronic
ethacrynic acid use?
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory alkaloses
d. Potassium retention
e. All of the above
184. Which of the following drugs is most similar to
steroids in its chemical composition?
a. Triamterene
b. Spironolactone
c. Ethacrynic acid

d.
e.

Cardiovascular Disorders

127

Sucrose
Chlorothiazide

185. Which of the following acts via inhibition of


aldosterone at the distal tubule?
a. Triamterene
b. Spironolactone
c. Ethacrynic acid
d. Sucrose
e. Chlorothiazide
186. Which of the following is potassium sparing and
does not act at the renal cortex?
a. Triamterene
b. Spironolactone
c. Ethacrynic acid
d. Sucrose
e. Chlorothiazide
187. Which of the following is useful in the management
of volume-dependent hypertension but carries a risk
of hypokalemic alkalosis?
a. Triamterene
b. Spironolactone
c. Ethacrynic acid
d. Sucrose
e. Chlorothiazide
188. Which of the following may occur with
hypercalcemia caused by thiazide diuretics?
a. Increased serum phosphorus
b. Decreased serum phosphorus
c. Hypercalciuria
d. Hypocalciuria
e. a and c
189. Which of the following is an effect of furosemide?
a. Increased glomerular filtration rate
b. Decreased renin production
c. Decreased aldosterone
d. a and b
e. a and c
190. Which of the following is NOT a complication of
thiazide diuretics?
a. Hyperuricemia
b. Hyperglycemia
c. Hyperkalemia
d. Hyponatremia
e. Alkalosis
191. Which of the following is NOT a complication of
thiazide diuretics?
a. Thrombocytopenia
b. Jaundice
c. Photosensitivity
d. Hypokalemic nephropathy
e. All of the above are potential complications of
thiazides
192. Which of the following may result in
hyperkalemia?
a. Triamterene

128

SECTION II

b.
c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Acetazolamide
Hydrochlorothiazide
Ethacrynic acid
Mercurials

193. Which of the following is an effect of thiazideinduced excretion of sodium, chloride, and
water?
a. Increased glomerular filtration rate
b. Acid-base imbalance
c. Indirect effects on renal function
d. Inhibition of tubular electrolyte transport
e. Inhibition of carbonic anhydrase

200. Which of the following is a contraindication to


spironolactone use?
a. Hepatic insufficiency
b. Renal insufficiency
c. Coronary insufficiency
d. Asthma
e. Depression
201. Captopril may cause all of the following EXCEPT:
a. angioedema.
b. cough.
c. rash.
d. nasal congestion.
e. Captopril may cause all of the above

194. Which of the following is the primary mechanism


underlying the chronic antihypertensive effects of
oral diuretics?
a. Decreased plasma volume
b. Saluresis
c. Decreased potassium
d. Decreased adrenergic output
e. Decreased cardiac output

202. Which of the following is a carbonic anhydrase


inhibitor?
a. Mannitol
b. Traimterene
c. Acetazolamide
d. Furosemide
e. Chlormerodrin

195. Which of the following is a potential side effect of


spironolactone?
a. Gynecomastia
b. Hyponatremia
c. Azotemia
d. a and b
e. a, b, and c

203. What is the primary mechanism of action of


diuretics for the treatment of edema?
a. Reduces total body sodium
b. Reduces plasma renin
c. Reduces vascular smooth muscle activity
d. Reduces sympathetic tone
e. Depletes potassium

196. Which of the following is a side effect of ethacrynic


acid?
a. Alkalosis
b. Hyperuricemia
c. Potassium loss
d. a and b
e. a, b, and c

204. Which of the following may cause hyperkalemia,


menstrual irregularities, and gynecomastia?
a. Triamterene
b. Spironolactone
c. Captopril
d. Amiloride
e. All of the above

197. Which of the following does NOT cause


hypokalemia?
a. Triamterene
b. Hydrochlorothiazide
c. Flumethiazide
d. Chlorthalidone
e. Bendroflumethiazide

205. Which of the following is/are contraindicated in


patients receiving potassium replacement therapy?
a. Bumetanide
b. Traimterene
c. Amiloride
d. a and b
e. b and c

198. Which of the following may cause hypochloremic


alkalosis with prolonged use?
a. Ethacrynic acid
b. Furosemide
c. Mannitol
d. a and b
e. a, b, and c

206. Which of the following may cause metabolic


alkalosis?
a. Furosemide
b. Hydrochlorothiazide
c. Bumetanide
d. a and b
e. a, b, and c

199. Which of the following statements about traimterene


is true?
a. It is sodium sparing.
b. It is not used clinically.
c. It can cause hyperkalemia.
d. It is an aldosterone antagonist.
e. It interacts with spironolactone.

207. Which of the following should NOT be given


concomitantly with spironolactone?
a. Monoamine oxidase inhibitors
b. Epinephrine
c. Propranolol
d. Potassium
e. All of the above

CHAPTER 10

208. Which of the following may occur with


spironolactone therapy?
a. Hypomagnesemia
b. Hyperkalemia
c. Bronchospasm
d. Acne
e. Male pattern baldness
209. Which of the following is the correct site of action of
mannitol?
a. Distal tubule
b. Proximal tubule
c. Descending loop of Henle
d. Ascending loop of Henle
e. All of the above
210. Which of the following is contraindicated in
hyperkalemic patients?
a. Acetazolamide
b. Furosemide
c. Spironolactone
d. Ethacrynic acid
e. Chlorothiazide
211. Which of the following is NOT a mixed or indirect
acting molecule?
a. Amphetamine
b. Dobutamine
c. Dopamine
d. Ephedrine
e. None of the above
212. Which of the following does NOT occur with
ganglion blockade?
a. Bradycardia
b. Arteriolar vasodilation
c. Hypotension
d. Decreased cardiac output
e. Constipation
213. Digoxin maintenance dosing is based on:
a. pulmonary function.
b. hepatic function.
c. protein level.
d. renal function.
e. serum potassium.
214. Which of the following lowers triglycerides most
effectively?
a. Colestipol
b. Atorvastatin
c. Gemfibrozil
d. Cholestyramine
e. Lovastatin
215. Which of the following may produce myalgia,
abdominal pain, and gallstones?
a. Clofibrate
b. Nicotinic acid
c. Colestipol
d. Probucol
e. Lovastatin

Cardiovascular Disorders

129

216. Which of the following statements is true?


a. Atorvastatin increases LDL.
b. Lovastatin decreases HDL.
c. Neomycin increases LDL.
d. Nicotinic acid reduces VLDL and triglycerides
only.
e. Clofibrate acts primarily to decreased VLDL and
triglycerides.
217. Which of the following is commonly used to enhance
the activity of HMG-CoA reductase inhibitors?
a. Gemfibrozil
b. Cholestyramine
c. Lovastatin
d. Probucol
e. D-Thyroxine
218. Which of the following is an HMG-CoA reductase
inhibitor?
a. Gemfibrozil
b. Clofibrate
c. Lovastatin
d. Colestipol
e. Niacin
219. Ingestion of aspirin 30 minutes before niacin may
reduce which of the following?
a. Flushing
b. Myositis
c. Hepatic injury
d. Diarrhea
e. Acanthosis nigricans
220. Which of the following may occur with niacin?
a. Flushing
b. Hyperglycemia
c. Jaundice
d. Hyperuricemia
e. All of the above
221. Which of the following may cause hyperkalemia,
gynecomastia, and menstrual irregularities?
a. Trimaterene
b. Spironolactone
c. Amiloride
d. a and b
e. b and c
222. Which of the following may cause hyperkalemia in a
patient taking concomitant oral potassium?
a. Triamterene
b. Amiloride
c. Mannitol
d. a and b
e. a and c
223. Which of the following may cause metabolic
acidosis?
a. Furosemide
b. Bumetanide
c. Hydrochlorothiazide
d. All of the above
e. None of the above

130

SECTION II

PHARMACOTHERAPY IN PRACTICE

224. Which of the following is a cardioselective beta


blocker?
a. Timolol
b. Metoprolol
c. Atenolol
d. a and b
e. b and c

232. Which of the following is a contraindication to


captopril use?
a. Bilateral renal artery stenosis
b. Depression
c. Angina
d. COPD
e. Prostatic hypertrophy

225. Which of the following does NOT cause reflex


tachycardia?
a. Clonidine
b. Reserpine
c. Minoxidil
d. a and b
e. a and c

233. A 74-year-old man has blood pressure of 135/86 mm


Hg. This patient has:
a. normal blood pressure.
b. high normal blood pressure.
c. mild (stage 1) hypertension.
d. moderate (stage 2) hypertension.

226. Which of the following is least likely to produce


CNS effects?
a. Timolol and metoprolol
b. Timolol and atenolol
c. Nadolol and timolol
d. Nadolol and atenolol
e. Metoprolol and nadolol
227. Which of the following is most similar to
guanadrel?
a. Guanethidine
b. Methyldopa
c. Clonidine
d. Guanabenz
e. Methyldopa
228. Which of the following adverse effects may occur
with guanethidine?
a. Diarrhea
b. Sympathomimetic hypersensitivity
c. Orthostatic hypotension
d. All of the above
e. None of the above
229. Which of the following adverse effects may occur
with hydralazine?
a. Reflex tachycardia
b. Hypertrichosis
c. Orthostatic hypotension
d. a and b
e. b and c
230. Dyazide contains a potassium-sparing diuretic and
what other type of drug?
a. Nitrate
b. Thiazide
c. Nitrofurantoin
d. Dopamine antagonist
e. Sulfonamide
231. Which of the following is an effect of
epinephrine?
a. Cardiac stimulation
b. Bronchodilation
c. Peripheral vasodilation
d. All of the above
e. a and c

234. Which of the following parameters should be


monitored in a patient receiving heparin?
a. Partial thromboplastic time
b. Prothrombin time
c. Bleeding time
d. Platelet count
e. Serum potassium
235. Which medication is the antihypertensive drug of
choice during pregnancy?
a. Propranolol
b. Methyldopa
c. Nicardipine
d. Enalapril
e. None of the above
236. Bumex is similar to which of the following?
a. Plavix
b. Demadex
c. Vytorin
d. Nexium
e. Lescol
237. True or False: Sustained-release nifedipine products
may cause what looks to be an intact tablet in the
stool.
a. True
b. False
238. Which of the following is a side effect of
nifedipine?
a. Peripheral edema
b. Weakness
c. Nausea
d. Palpitations
e. All of the above
239. All of the following are adverse effects of ACE
inhibitors EXCEPT:
a. neutropenia.
b. proteinuria.
c. hyperkalemia.
d. dry, hacking cough.
e. sialism.
240. Which of the following drugs is contraindicated in
patients with CHF?
a. Verelan

CHAPTER 10

b.
c.
d.
e.

Catapres
Vasotec
Diuril
Nitrostat

241. Which of the following drug(s) exhibits antiplatelet


action?
I. Ticlopidine
II. Dipyridamole
III. Acetylsalicylic acid
a.
b.
c.
d.
e.

I only
III only
I and III
II and III
I, II, and III

242. Digitalis toxicity is associated with:


I. decrease in serum concentration of K.
II. decrease in serum concentration of Mg.
III. increase in serum concentration of Ca.
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

Cardiovascular Disorders

131

247. Reflex tachycardia, headache, and postural


hypotension are adverse effects that limit the
use of which of the following antihypertensive
agents?
a. Prazosin
b. Captopril
c. Methyldopa
d. Guanethidine
e. Hydralazine
248. Which of the following medications commonly
causes thiocyanate intoxication, hypotension, and
convulsions?
a. Ramipril
b. Methyldopa
c. Nitroprusside
d. Terazosin
e. Penbutolol
249. Which of the following is LEAST effective in the
presence of metabolic acidosis?
a. Triamterene
b. Spironolactone
c. Acetazolamide
d. a and b
e. a, b, and c

243. Clonidine does NOT cause which of the following


side effects?
a. Asthma
b. Hypertension
c. Lethargy
d. Dry mouth
e. Dizziness

250. Which of the following is lost in the urine with


acetazolamide therapy?
a. Hydrogen
b. Glucose
c. Bicarbonate
d. Glycine
e. All of the above

244. Which of the following statements about alpha


receptors is FALSE?
a. Methoxamine and phenylephrine are alpha-2
selective.
b. Clonidine is alpha-2 selective.
c. Prazosin is alpha-1 selective.
d. Epinephrine is nonselective.
e. Phetolamine is nonselective.

251. Which of the following statements about mannitol is


true?
a. It acts on the proximal tubules to promote
sodium and water retention.
b. It is useful for the reduction of intracranial
pressure.
c. It is safe to use in patients with acute renal
failure.
d. It may cause hypoglycemia.
e. It is a first-line agent for the treatment of
hypertension in diabetics.

245. Which of the following agents has a direct effect on


the AV node, delaying calcium-channel
depolarization?
a. Lidocaine
b. Verapamil
c. Bretylium
d. Quinidine
e. Nidfedipine
246. Which of the following drugs is a class III
antiarrhythmic agent that is effective in the acute
management of ventricular tachycardia, including
ventricular fibrillation?
a. Bretylium
b. Lidocaine
c. Metoprolol
d. Disopyramide
e. Diltiazem

252. Digitoxin has a half-life of:


a. 12 hours
b. 24 hours
c. 48 hours
d. 5 days
e. 7 days
253. A patient with a medical history significant for major
depressive disorder (MDD) has new-onset
hypertension. Based on her history of MDD, what
medication should be avoided in this patient?
a. Catapres
b. Lasix
c. Inderal
d. Cordarone
e. All of the above medications are safe

..................................................

Dermatologic Disorders

11
CHAPTER

...................................................................................................................................................................

I. Acne
Acne is an inflammatory disease of the sebaceous glands
(oil-producing glands) and hair follicles of the skin. Acne
is marked by the eruption of pimples or pustules,
especially on the face, back, and chest. Typically, acne
treatments take four to eight weeks for full results.
A. Conventional acne treatments are based on the
concepts of:
1. Reducing sebum production
2. Speeding up skin cell turnover
3. Fighting bacterial infection (i.e., Propionibacterium
acnes)
B. Over-the-counter (OTC) topical treatments may dry
up the oil, reduce bacteria, and promote exfoliation.
1. Benzoyl peroxide (e.g., Clean and Clear, PersaGel, Oxy 10 Spot Treatment)
a) Also available in prescription preparations
alone or in combination with sulfur or a
topical antibiotic
2. Salicylic acid (e.g., Biore Blemish Bomb,
Clearasil Stay Clear, Zone Control Clearstic).
3. Sulfur and/or resorcinol (e.g., Clearasil Adult
Care)
NOTE: Common side effects for all topical
retinoids include skin dryness, peeling, redness,
photo sensitivity
C. Prescription topical retinoid products that are
derived from vitamin A work by promoting cell
turnover and preventing blockage of the hair follicle.
1. Tretinoin (Avita, Retin-A, Renova)
2. Adapalene (Differin)
3. Tazarotene (Tazorac)
D. Antibiotics
For moderate to severe acne (inflammatory or
nodulocystic acne), prescription oral or topical
antibiotics may be needed to reduce bacteria and
fight inflammation. Antibiotics may be used for
months or years to control acne and may be used
alone or in combination with topical therapy.
Antibiotics can also lessen the effectiveness of
birth control pills by killing beneficial bacteria in
the gastrointestinal tract that are responsible for
hormone metabolism.
1. Erythromycin (Erygel, Emcin, Emgel, Aknemycin, others)
a) Anti-inflammatory properties that help
reduce redness in lesions, in addition to
killing bacteria
b) Dose
(1) Varies with the type used
132

(2) Topical application (gel, solution,


medicated pledget): Applied twice daily
to affected area(s).
(3) If given systemically, initial dose 500 mg
PO twice a day and taken with food; dosage
reduced to 250500 mg/day PO after
several weeks once improvement is seen.
c) Side effects
(1) Stomach upset and nausea, but can be
used in pregnant women
2. Clindamycin (Cleocin T, Clindagel, Clindaderm,
Evoclin, others)
a) Widely prescribed as a topical antibiotic for
acne, rarely used systemically for acne due
to side-effect profile
b) Topical dose
1) Gel, solutions, or lotion: Applied twice
daily to affected area(s)
2) Foam: Applied once daily to affected area(s)
c) Side effects
(1) Serious intestinal infection,
pseudomembranous colitis, caused by
the bacteria Clostridium difficile. This
side effect has been reported rarely with
topical clindamycin use.
3. Tetracycline
a) Most widely prescribed oral antibiotic for acne
b) Dose
(1) Initially, 500 mg PO twice a day until a
significant decrease in acne lesions is
seen; dose may then be decreased to
250500 mg PO once a day.
(2) Tetracycline antibiotics must be taken
on an empty stomach to be most
effective.
c) Caution
(1) Not recommended for pregnant women
or children younger than 9 years
because tooth discoloration of the
forming teeth is common in children. If
all permanent teeth have erupted,
tetracycline antibiotics may be a choice
in select preteens.
(2) All tetracyclines may cause sun
sensitivity.
d) Other tetracyclines used for acne include
minocycline (Minocin, initially 50100 mg PO
twice daily, especially useful for pustular
type acne) and doxycycline (Vibramycin,
initially 50100 mg PO twice daily).

CHAPTER 11

II.

4. Isotretinoin (Accutane, Claravis, Sotret)


a) Effective for scarring cystic acne or acne that
does not respond to other treatments. It is
reserved for the most severe forms of acne.
b) Side effects
(1) Severe mental disorders including
depression and suicide
(2) Heart, brain, bone/muscle,
gastrointestinal, cholesterol, hearing,
vision, and liver problems
(3) Severe allergic reactions
(4) Teratogenic
c) Caution
(1) Close monitoring is essential to
possibility of severe birth defects
(2) Contraindicated in women trying to
become pregnant or during pregnancy
(3) Pharmacists must also provide a
detailed warning brochure called a
MedGuide from the United States Food
and Drug Administration (FDA) to all
patients prescribed isotretinoin. All
prescribers, pharmacies, and patients
must also register and participate in the
iPledge risk-management program in
order to prescribe, dispsense, or receive
the drug.
E. Oral contraceptives (OC)
1. May exacerbate or improve acne depending on
the progesterone components androgenic
activity. Those with greater androgenic activity
(levonorgestrel) tend to exacerbate acne, and
those with less (norgestimate) or no
(drospirenone) androgenic activity have been
reported to improve acne in women.
2. Oral contraceptives increase the risk of
thromboembolic events, especially in women
older than 35 years who smoke.
Remember ACHES acronym to remember
thromboembolic warning signs: Abdominal
pain, Chest pain, Headache or pain or changes
in the eyes, severe pain or swelling in the legs
or the thighs
3. Adverse effects include breast enlargement
and tenderness, GI upset, irregular vaginal
bleeding, especially during the first 3 months of
therapy.
4. Examples of OC brands that are FDA approved
for the treatment of acne (acne dosage is the
same as for the OC regimen):
a) Ethinyl estradiol; Drospirenone (Yaz)
b) Ethinyl estradiol; Norethindrone acetate
(Estrostep)
c) Ethinyl estradiol; Norgestimate (Ortho TriCyclen)
Alopecia
A. Alopecia areata: an autoimmune disorder in which
the bodys immune system attacks hair follicles,
resulting in unpredictable patches of hair loss on
the scalp, face, and other parts of the body.
1. Treatment
a) Corticosteroids: betamethasone (Celestone),
monthly injections into the scalp
b) Corticosteroid pills

Dermatologic Disorders

133

c) Corticosteroid creams and ointments, such


as betamethasone (Diprolene), have been
applied to affected areas of the skin.
However, creams and ointments are
generally less effective than injections.
B. Androgenic alopecia: an inherited form of
baldness. Unlike men, women rarely develop
complete baldness. Women usually experience
hair thinning only.
1. Treatment
a) Minoxidil (Rogaine)
(1) Available OTC. Applied directly to the
area of hair loss at least two times a day
for at least 4 months. The medication
usually does not take effect until
4 months to 1 year.
(2) Mechanism of action
(a) Enlarges hair follicles
(3) Caution
(a) Patients who discontinue use of
minoxidil will likely lose the hair that
they have already grown.
b) Finasteride (Propecia)
(1) Only works in men. This pill must be
taken daily to regrow hair.
(2) Dose
(a) 1 mg PO once daily
(3) Mechanism of action
(a) Inhibits high levels of
dihydrotestosterone (DHT) around
hair follicles. High amounts of DHT
cause hair follicles to shrink, and
hair falls out as a result.
(4) Caution
(a) Pregnant women and women hoping
to become pregnant should avoid
contact (including topical contact)
with finasteride due to the risk of
genital abnormalities to a male fetus.
c) Spironolactone (Aldactone)
(1) Originally marketed as a diuretic (water
pill) for patients suffering from
congestive heart failure. Women now
take the drug off-label because its
antiandrogen properties may stop and
sometimes reverse hair loss. It may also
be more effective in postmenopausal
women and may be taken with a
hormone replacement pill.
(2) It is taken initially at a low dosage
(25 mg) once or twice daily. Incremental
dosage increases may be used, if needed.
(3) This medication may take many months
to show results in women.
d) Cimetidine (Tagamet)
(1) Initially used as a prescription drug to treat
heartburn and stomach ulcers. Recently,
this medication became available OTC.
(2) Although primarily used as a histamineblocking agent, it is also has some
antiandrogen effects and thus only
works for women. Cimetidine has been
used off-label to treat androgenic
alopecia in women.

134

SECTION II

PHARMACOTHERAPY IN PRACTICE

III. Dry Skin (Xerosis)


A. Treatment with emollients and/or keratolytic agents;
usual application is twice per day, unless otherwise
noted on label or directed by prescriber.
1. Lactic acid, glycolic acid, salicylic acid, urea,
and sulfur
2. Ammonium lactate (Lac-Hydrin, others)
3. Petrolatum (Aquaphor)
IV. Dermatitis
A. Atopic dermatitis (eczema) is a chronic disease,
and symptoms can disappear and recur over time.
The skin of an affected individual is flaky, red, and
itchy. The skin covering the joints and face is most
commonly affected. Symptoms can be managed.
Minimizing contact with known allergens can
reduce the severity of symptoms.
1. Treatment
a) Avoidance of any exacerbating allergens,
contact irritants, foods, or environmental
factors
b) Antianxiety medications: The condition can
cause stress and anxiety; nonpharmacologic
methods to reduce stress factors are
typically employed before medication
c) Antibiotics: If co-infection exists
d) Antihistamines like diphenhydramine (e.g.,
Benadryl) and hydroxyzine (e.g., Atarax)
e) Calcineurin inhibitors like pimecrolimus
(Elidel) and tacrolimus (Protopic)
f) Immunosuppressants such as cyclosporine
or interferon
g) Oral corticosteroids such as prednisone and
prednisolone
h) Topical corticosteroids such as
hydrocortisone, betamethasone, or
fluticasone propionate or OTC
hydrocortisone (e.g., Bactine, Cortaid,
Dermolate, or Aveeno Anti-Itch cream).
Higher-strength (>1%) topical
corticosteroids are available by
prescriptions only.
B. Contact dermatitis: a rash that develops after
contact with an allergen or skin irritant. Poison ivy,
poison oak, and poison sumac produce urushiol, an
oil and the allergen responsible for the allergic
reaction that usually develops 2448 hours after
contact with the oil. However, it can take several
days to 12 weeks for the rash to resolve. Patients
who are allergic to these plants may experience a
rash that consists of swollen, itchy, red bumps and
blisters that appear wherever the oil has touched
the skin.
1) Prevention: Avoidance of contact irritants,
wearing of protectant clothing and gloves if
irritant exposure is possible or cannot be
avoided, skin protectant lotions like Ivy-Block
can be tried, but must be applied at least 15
minutes before exposure and reapplied often
(after 4 hours) if activity is prolonged.
2) Treatment and relief from symptoms
(a) General care includes removal of
contaminated clothing and washing the
affected skin with soap and cool water.

Washing within 10 minutes of exposure may


help limit the reaction.
(b) Systemic antihistamine such as
diphenhydramine (Benadryl). Topical
application of diphenhydramine is not
recommended because it can cause
sensitization.
(c) Calamine lotion (e.g., Calamox) applied
three to four times per day; allow to dry
before putting on clothing
(d) Cool showers or compresses
(e) Colloidal oatmeal such as Aveeno Oatmeal
Bath
(f) Topical corticosteroids (e.g., hydrocortisone
cream)
(g) Oral corticosteroids (e.g., prednisone used
for refractory cases or cases with
complications)
(h) Consumers often tout the usefulness of
home remedies for relief from itching,
including baking soda, vinegar, and aloe
vera
V. Pediculosis and Scabies
Lice and scabies are two types of skin conditions that are
caused by ectoparasites, parasites that that live on the
outside of their hosts.
A. Treatment
1. General
a) Treated with OTC products and/or
prescription-strength antiparasitic
medications.
b) To prevent reinfection, it is recommended
that individuals wash and vacuum items that
may be contaminated.
c) Individuals who live with or have close
personal contact with someone who has lice
or scabies should receive treatment as well.
2. OTC
a) Pyrethrins and piperonyl butoxide (e.g.,
Pronto) do not kill nits, need to re-treat in
710 days
b) Permethrin (e.g., Nix, RID) kills lice and eggs,
may require only one application
3. Prescription
a) Malathion (Ovide)
b) Lindane (Kwell) Caution: Neurotoxic.
Inappropriate application, inappropriate
contact, or too-frequent or excessive
application may cause seizures and other
serious reactions.
4. Scabicides, such as Lindane, permethrin
(Acticin or Elimite), or crotamiton (Eurax Cream
or Eurax Lotion)
5. Antihistamines
VI. Warts
A. Common warts, flat warts, plantar warts (caused
by human papillomaviruses [HPV])
1. Treatment
a) Salicylic acid 17% (Compound W, OcclusalHP)
b) Patient-administered cryotherapy OTC
products (e.g., Compound W Freeze-Off)
c) Provider-administered cryotherapy

CHAPTER 11

B. Anogenital warts (caused by select types of HPV)


1. Treatment
a) Administered by physician
(1) Cryotherapy with liquid nitrogen,
cryoprobe weekly, or surgical removal
(2) Podophyllin resin, 10%25% weekly for a
maximum of 4 weeks
(3) Trichloroacetic acid or bichloroacetic
acid, 80%90% weekly
b) Administered by patient, but available by
prescription only after proper diagnosis
(1) Podofilox (Condylox), 0.5% solution or
gel twice daily for 3 days, followed by
4 days without therapy. This cycle may
be repeated four times.
(2) Imiquimod (Aldara), 5% cream three
times per week for a maximum of 16
weeks
VII. Psoriasis
Psoriasis is a chronic skin disease characterized by scaly,
reddish patches and itching. The inflammation sometimes
manifests as silvery scales that appear on elbows, knees,
scalp, and torso. It is not contagious. The cause is
generally unknown, although recent studies suggest that it
is an autoimmune disorder.
A. Topical treatments for localized exacerbations
1. Corticosteroids
2. Calcipotriene (Dovonex): applied to affected
area once or twice daily
3. Tazarotene (Tazorac): applied once daily to
affected area
4. Coal tar
B. Systemic treatments
1. Oral
a) Methotrexate
(1) Antimetabolite
(2) Dosed weekly
(3) Adverse effects: hepatotoxicity,
pulmonary toxicity, pancytopenia,
potential for increased malignancies,
ulcerative stomatitis, nausea, diarrhea,
teratogenicity
b) Acitretin (Soriatane)
(1) Retinoid
(2) Adverse effects: teratogenicity,
osteophyte formation, hyperlipidemia,
flare of inflammatory bowel disease,
hepatoxicity, depression
c) Cyclosporine (Neoral, Sandimmune)
(1) Calcineurin inhibitor
(2) Adverse effects: renal dysfunction,
hypertension, hyperkalemia,
hyperuricemia, hypomagnesemia,
hyperlipidemia, increased risk of
malignancies
d) Methoxsalen
(1) Psoralen photosensitizing agent
(2) Used in conjunction with UVA light
exposure therapy
2. Parenteral
a) Alefacept (Amevive)
(1) Anti-CD-2
(2) IM injection once weekly for 12 weeks

Dermatologic Disorders

135

(3) Adverse effects: Lymphopenia, potential


for increased malignancies, serious
infections
b) Etanercept (Enbrel)
(1) Anti-Tumor Necrosis Factor Alpha
(TNF-a)
(2) Approved for psoriasis and psoriatic
arthritis
(3) SC injection once or twice weekly
(4) Adverse effects: serious infections,
neurologic events, hematologic events,
potential for increased malignancies
c) Efalizumab (Raptiva)
(1) Anti-CD-11a
(2) SC injection once weekly
(3) Adverse effects: serious infections,
potential for increased malignancies,
thrombocytopenia, hemolytic anemia,
worsening psoriasis
d) Adalimumab (Humira)
(1) Anti-TNF-a
(2) Approved for psoriatic arthritis
(3) SC injection every other week
(4) Adverse effects: serious infections,
neurologic events, potential for
increased malignancies, hypersensitivity
reactions, hematologic events
e) Infliximab (Remicade)
(1) Anti-TNF-a
(2) Approved for psoriatic arthritis
(3) IV infusion at weeks 1, 2, and 6, then
every 8 weeks
(4) Adverse effects: serious infections,
hepatotoxicity, hematologic events,
hypersensitivity reactions, neurologic
events, potential for increased
malignancies
VIII. Common Dermatologic Fungal Infections
A. Tinea corporis (ringworm)
B. Tinea cruris (jock itch)
C. Tinea pedis (athletes foot)
1. Topical treatment with azole antifungals;
many agents available without prescription
(OTC)
2. Longer duration of therapy required for tinea
pedis versus other tinea infections
D. Onychomycosis (toenails or fingernails)
1. Mild infections may be treated with topical
antifungal lacquers (e.g., ciclopirox,)
2. Oral antifungal medication (e.g., itraconazole,
terbinafine) may be required for several
months
IX. Dermatologic Bacterial Infections
A. Impetigo (S. aureus or S. pyogenes): Highly
contagious skin condition, with small oozing,
crusting blisters, it usually begins on hands or face
and rapidly spreads.
1. Treatment
a) Topical antibiotics (mupiricin [Bactroban]
2%, retapamulin [Altabax])
b) Oral antibiotics (e.g., amoxicillin/clavulanate
[Augmentin], cefadroxil [Duricef],
levofloxacin [Levaquin])

136

SECTION II

PHARMACOTHERAPY IN PRACTICE

PATIENT PROFILE

Answer: d. Given the extensive nature of THs disease


(greater than 20% of body) and information from the
course of his treatment history and current
medications, topical nonprescription corticosteroids
would not be recommended. Nonprescription
corticosteroid products would not be of sufficient
potency to be helpful. Topical corticosteroids and
calcipotriene topically are typically used as first-line
therapy in patients with limited psoriatic plaques.
TH does not have limited disease and already
receives systemic corticosteroid treatment. Current
guidelines recommend that all patients with psoriasis
maintain good skin hygiene. Nearly all patients with
psoriasis generally find emollients and keratolytic
agents helpful in improving skin appearance and
reducing skin itching.

Patient Initials: TH
Sex: Male
Age: 43 years
Height: 50 1100
Weight: 82 kg
Race: White
Allergies: Penicillin
Chief Complaint:
RM is a 43-year-old man seeking pharmacist assistance for
the ongoing topical maintenance management of his
psoriasis. His condition is classified as moderate to severe
and has affected his joints (symptoms and signs in his
hands and knees are consistent with psoriatic arthritis). He
has scaling and plaques on more than 20% of his skin.
Recent History: TH underwent biologic aortic valve
replacement (BAVR) last month due to newly found
congenital valvular disease. He is doing well after open
heart surgery to replace the valve.

2.

Social History:
Tobacco use: None
Alcohol use: 1 beer per week, socially
Work: Unemployed; receives disability compensation due
to affect of psoriasis on the joints in hands (was formerly
a chef)
Exercise: Walks 2 miles daily for heart health and to
maintain joint mobility
Medications:
Prednisone 20 mg PO once daily
Tylenol with codeine #3 q6h prn pain (uses roughly once
or twice daily)
Metoprolol 25 mg PO twice daily
Warfarin 5 mg PO once daily
Multivitamin with minerals PO once daily

REVIEW QUESTIONS
(Answers and Rationales on page 356.)
1.

The hospital pharmacy in which you work has added


mometasone 0.1% cream as the preferred medium
potency topical steroid. Which of the following is a
medium potency topical steroid and is being replaced
by mometasone?
a. Desonide 0.05% cream
b. Mometasone 1% cream
c. Triamcinolone 0.1% cream
d. Clobetasol 0.05% cream
e. Clobetasol 10.0% cream

2.

Dexamethasone may be used in the treatment of all of


the following EXCEPT:
a. Addisons disease
b. dermatitis
c. asthma
d. osteoporosis

3.

Which of the following is first-line therapy for mild


rosacea?
a. Topical metronidazole
b. Adapalene gel
c. Oral doxycycline
d. Oral metronidazole for 7 days
e. a and c

Past medication notes: No longer taking Naprosyn 500 mg


PO twice daily after open heart surgery due to warfarin
prescription, which is expected to continue for another
2 months; had to discontinue infliximab (Remicade)
infusion treatments last year due to cardiac symptoms
(slight symptoms of mild heart failure).
PATIENT PROFILE QUESTIONS
1. TH asks the pharmacist about skin hygiene
tactics that may be useful in limiting scaling and
improving skin appearance and that would not
interact with his current prescribed medications.
Which of the following topical skin care adjuncts
are typically recommended for patients with
psoriasis?
I. Emollients
II. Keratolytics
III. Topical nonprescription corticosteroids
a.
b.
c.
d.
e.

I only
II only
III only
I and II
I and III

Which of the following is an example of a keratolytic


agent that TH might employ?
a. AmLactin
b. Eucerin Creme
c. PsoriGel
Answer: a. AmLactin contains lactic acid, a
keratinolytic agent. Keratinolytics break down
keratin, a fibrous protein in skin cells, and this
process helps remove the dead, keratinized cells of
the stratum corneum (outer skin layer). Skin may
look smoother after the use of these agents, which may
help plaque appearance. The original formula of
Eucerin creme contains emollients to increase skin
hydration. PsoriGel (coal tar) may decrease skin
proliferation and have anti-inflammatory properties;
however, a precise mechanism in psoriasis is not clear.

CHAPTER 11

d.
e.

Read the following case study and then answer the


questions that follow.
A 25-year-old woman with no medical history presents to
a clinic with a rash that has lasted 3 months. The rash is
limited to the posterior elbows and knees and is not
pruritic. On examination, the rash is scaly and white with
an erythematous edge. It is sharply demarcated and
raised from the surrounding normal skin. She reports a
similar rash in her mother that lasted several years.
4.

5.

6.

Which of the following increases the risk of psoriasis?


a. Smoking
b. Old age
c. Low body weight
d. Over-cleansing of skin
e. Exposure to animals
What is an appropriate treatment for mild psoriasis?
a. Topical hydrocortisone
b. Oral prednisone
c. Methotrexate
d. Avoidance of sunlight
e. Any of the above
How does methotrexate alleviate psoriasis?
a. Prevention of fungal growth
b. Stimulation of epidermal regeneration
c. T-cell suppression

Dermatologic Disorders

137

Mast cell stimulation


Antiangiogenic effects

7.

Which of the following is a high potency steroid in


appropriate strength for second-line psoriasis
treatment?
a. Clobetasol 5%
b. Clobetasol 0.05%
c. Betamethasone 0.01%
d. Betamethasone 1%
e. Halcinonide 10%

8.

Side effects of topical corticosteroids include:


a. pruritus
b. erythema
c. folliculitis
d. hypertrichosis
e. All of the above

9.

Which of the following is NOT an indication for


methotrexate?
a. Lymphoma
b. Rheumatoid arthritis
c. Esophageal cancer
d. Choriocarcinoma
e. All of the above are indications for
methotrexate

..................................................

12

Common Endocrinologic
Disorders

CHAPTER

...................................................................................................................................................................

I. Diabetes Mellitus
Diabetes mellitus (DM) is a metabolic disorder
characterized by glucose intolerance. People in the United
States who are at the highest risk for diabetes are Latino
Americans, African Americans, Native Americans, and
Asian Americans. It is the leading cause of blindness in
adults as well as a major cause of end-stage renal disease
and amputations.
A. Classification
1. Type 1 diabetes is a failure of the pancreas to
make enough insulin for the body to function.
It was previously called insulin-dependent
diabetes or juvenile-onset diabetes. It occurs
more often in younger patients than older
patients. Type 1 diabetes requires insulin
therapy.
2. Type 2 diabetes refers to decreased insulin
production from the pancreas, decreased
sensitivity of cells to insulin, and decreased
ability to get glucose into cells. It was
previously called noninsulin dependent
diabetes and adult-onset diabetes. It occurs
more often in older patients than younger
patients, although the incidence of type 2
diabetes is increasing in children in the United
States. Patients may start with diet and exercise
therapy. Most patients start with oral medications
but may progress to requiring insulin therapy.
3. Gestational diabetes is diabetes that occurs
during pregnancy. It does not mean the patient
will have diabetes for the rest of her life, but she
will have increased risk of developing type 2
diabetes. Patients typically use insulin therapy
due to risk to the fetus when using oral
antidiabetic medications. Gestational diabetes is
usually detected through administration of an
oral glucose tolerance test (OGTT) during
pregnancy.
4. Prediabetes is the increased risk of developing
DM.
a) Impaired fasting glucose (IFG): fasting
glucose 100125 mg/dL
b) Impaired glucose tolerance (IGT): Two-hour
glucose 140199 mg/dL during oral glucose
tolerance test (OGTT)
B. Signs and symptoms
1. The 3 Ps: polyuria, polydipsia, polyphagia
2. Blurred vision
3. Fatigue
4. Dry, itchy skin
138

5. Slow wound healing


6. Weight loss (type 1 diabetes)
C. Diagnosis
1. Random plasma glucose > 200 mg/dL plus signs
and symptoms of diabetes OR
2. Fasting plasma glucose > 126 mg/dL OR
3. Two-hour postprandial glucose > 200 mg/dL
during OGTT
4. Confirm the above.
5. Hemoglobin A1c testing (HbA1c): HbA1c is not
used to diagnose DM, but is used for long-term
monitoring.
D. Goals of therapy

Goals of Therapy
Target Area
Preprandial plasma
glucose (fasting)
Postprandial plasma
glucose (after meals)
Glycosylated hemoglobin
(HbA1c)
Blood pressure
Lipid levels
LDL cholesterol
HDL cholesterol
Triglycerides

Treatment Goals (for the


patient with diabetes)
90130 mg/dL
<180 mg/dL
<7%
<130/80 mmHg
<100 mg/dL
>40 mg/dL (men);
>50 mg/dL (women)
<150 mg/dL

Based on the American Diabetes Association guidelines. Individual


treatment goals may vary slightly from these guidelines based on
personal medical history.

E. Treatment
1. Diet
2. Exercise
3. Type 1: insulin therapy, pramlintide (Symlin)
4. Type 2: oral agents and/or insulin, pramlintide
(Symlin), exenatide (Byetta)
F. Insulin
1. Background
a) Insulin is produced in the beta cells of the
pancreas. It is released at a basal rate of 0.5
to 1 U/h. Insulin response is increased in
response to food.

CHAPTER 12

b) The mechanism of action is not completely


understood.
(1) Muscle: increase glucose transport into
cell, glycogenesis, protein and
triglyceride synthesis
(2) Liver: increase glucose transport into
cell, glycogenesis, glucose utilization in
Krebs cycle, protein synthesis
(3) Adipose: increase glucose transport
into cell, glycogenesis, triglyceride
synthesis
(4) Take home point: Insulin is necessary
for the body to use glucose.
2. Types of insulin
a) Short-acting
(1) Used for mealtime control
(2) Administered 1530 minutes before
meal
(3) May also be used for sliding scale
(4) Examples
(a) Insulin aspart (NovoLog)
(b) Insulin lispro (Humalog)
(c) Insulin glulisine (Apidra)
(d) Regular (Humulin R)
b) Intermediate-acting
(1) Used for basal control
(2) Dosed twice daily for optimal control;
may also be dosed once daily at
bedtime for patients with type
2 diabetes who also take oral
medications to suppress overnight
hepatic gluconeogenesis
(3) Example
(a) Isophane insulin, NPH (Humulin N)
c) Long-acting
(1) Like intermediate-acting are used for
basal control
(2) Usually dosed once daily
(3) Should not be mixed with any other
insulin
(4) Examples
(a) Insulin glargine (Lantus)
(b) Insulin detemir (Levemir)
d) Combination products
(1) Humulin 70/30 (70% NPH, 30% regular)
(2) Humulin 50/50 (50% NPH, 50% regular)
(3) Humalog mix 50/50 (50% insulin lispro
protamine suspension, 50% lispro)
(4) Humalog mix 75/25 (75% insulin lispro
protamine suspension, 25% lispro)
(5) NovoLog mix 70/30 (70% insulin aspart
protamine suspension, 30% aspart)
3. Cautions
a) Causes hypoglycemia at high doses
b) Lispro has more rapid onset than regular
and should not be interchanged with it
c) Patients with type 1 DM should not use
once-daily dosing of insulin initially
d) Changes in insulin should only be made
under supervision of medical personnel
e) Caution is warranted when switching from
animal (either pork or bovine) to purified
porcine insulin or biosynthetic human

Common Endocrinologic Disorders

4.

5.

6.

7.

8.

139

insulin due to increased potentcy or


bioavailability and increased risk of
hypoglycemia.
f) Injection needles should not be reused
g) Insulin should not be used during
hypoglycemia
h) Insulin should still be used when ill (may
need more insulin when ill)
i) Use of lispro has not been studied in
pregnancy, fetal abnormalities occurred in
two infants
j) Contraindication: hypersensitivity to the
medications
k) Insulin dosing and use requires constant
patient education and monitoring
Interactions
a) Medications affecting glucose: may increase
or decrease effect of insulin
b) Pork and human insulin should not be
mixed or used together
Toxicity and side effects
a) Hypoglycemia
b) Lipodystrophy
c) Weight gain
d) Patients may develop resistance to insulin
treatment
e) Patients may develop sensitivity to animal
insulin
Remarks regarding insulin
a) Should always be dosed in units
(e.g., 10 units subcutaneous [SC])
b) Regular insulin solution should be clear
c) Mixing*
(1) Semilente/lente/ultralente: can be
mixed in any proportion
(2) Regular lente: bind immediately, if
mixed, must use immediately after
mixing or inject separately
(3) Lente phosphate-buffered insulin
(NPH, NovoNordisk, Humulin BR): must
never be mixed; lente will become
immediate-acting instead of delayed
(4) NPH and regular insulin can be
combined in the same syringe and
refrigerated for a maximum of 21 days
Injection technique
a) Use abdomen, arm, leg, or buttocks
b) Clean the injection area first with alcohol
c) Examine bottle and roll gently in hands
d) Inject air into vial, draw up desired dose
e) Pinch the skin with one hand, and insert
the needle at an angle of 45 90
f) Dispose of the syringe properly
g) Rotate the injection site
Adjusting insulin dose
a) Adjustments are made based on glucose
monitoring and HbA1c as well as pattern of
response

*When mixing regular and NPH, regular should be drawn up first or the
protamine in NPH will cause the regular insulin in the vial to become
cloudy (the same applies to mixing regular with any other insulin).

140

SECTION II

PHARMACOTHERAPY IN PRACTICE

Insulin Calculations
Starting Insulin: Staged Diabetes Management Guideline (SDM)
Guideline for starting and titrating background
insulin: Background insulin oral agent(s) insulin
glargine or insulin detemir
<70 mg/dL
140250 mg/dL
>250 mg/dL

Decrease 12 U
Increase 24 U
Increase 48 U

0.1 U/kg body weight if A1c levels are <9% (long acting
insulin)
0.2 U/kg body weight if A1c levels are 9%
Adjustments are made weekly based on fasting blood
glucose.
It is common to start insulin therapy by using
only insulin glargine (Lantus) at bedtime in combination
with oral agents. The use of background insulin with oral
antidiabetic agents is a common approach to initiate
insulin therapy. The average dose that was effective in
the Treat-to-Target study was 0.4 to 0.5 U/kg at bedtime.
Continue to escalate dose if goal is not reached. If the
dose surpasses 0.7 U/kg, transition return to
background insulin. Mealtime regimen is
recommended for tighter control.

Start
0.1 U/kg in morning and evening if A1c <9%
0.2 U/kg in morning and evening if A1c 9%
Total daily units
0.20.4 U/kg
Adjust weekly based on AM or PM blood glucose
Guidelines for starting and titrating background/
mealtime insulin: Long-acting insulin (insulin
glargine or insulin detemir) rapid-acting insulin
with meals
Blood Glucose

Adjust Insulin{

Prebreakfast

Long-acting (detemir or
glargine)

Prelunch

Rapid acting

AM

Presupper lunch

Rapid acting

Prebedtime
supper

Rapid acting

Start

If A1c <9%:
 0.1 U/kg long-acting insulin
 0.1 U/kg rapid-acting insulin
divided between meals
If A1c 9%:
 0.2 U/kg long-acting insulin
 0.2 U/kg rapid-acting insulin
divided between meals

Total units

0.20.4 U/kg

Adjust

Minimum weekly

Guideline for starting and titrating premixed insulin:


Premixed insulin Aspart 70/30 or Lispro premix 75/25
Blood Glucose
Adjust Insulin*
Prebreakfast

<70 mg/dL
140250 mg/dL
>250 mg/dL

Decrease PM 12 U
Increase PM 12 U
Increase PM 24 U

Presupper

<70 mg/dL
140250 mg/dL
>250 mg/dL

Decrease AM 12 U
Increase AM 12 U
Increase AM 24 U

*Stop secretagogue; consider continuing insulin sensitizer(s).


{
Adjust insulin by 12 U based on blood glucose pattern. Review insulin-to-carbohydrate ratios and activity. Stop secretagogue; consider
continuing insulin sensitizer(s).
From Staged Diabetes Management, ed 4 # 2005, International Diabetes Center at Park Nicollet, Minneapolis, MN. All rights reserved.
Reprinted with permission (1)800-637-2675; and Pearson J, Powers M: Systematically Initiating Insulin: The Staged Diabetes Management
Approach, The Diabetes Educator 32(Suppl)(1):23s25s, 2006.

b) Adjust basic insulin dose 12 units at


a time; 24 units or more for extreme cases
c) For every unit of rapid-acting insulin,
glucose may be reduced by 2550 mg/dL
d) Long-acting insulin should be adjusted
based on fasting glucose
9. Alternative methods of insulin administration
a) Pen
(1) Portable and convenient; an alternative
to vial and syringe
(2) NovoPen 3, Flex Pen (NovoLog,
NovoLog 70/30, Levemir)
(3) Humalog, Humalog mix 75/25, Humulin
N, Humulin 70/30
b) Pump
(1) Continuous subcutaneous infusion

c) Inhaled insulin (Exubera)


(1) Withdrawn from the market due to lack
of demand
(2) High cost
(3) Long-term pulmonary safety profile of
concern
10. Somogyi effect and dawn phenomenon
a) Somogyi effect
(1) Rebound hyperglycemia due to insulininduced hypoglycemia
(2) Treatment
(a) Adjust evening snack
(b) Decrease evening NPH or give at a
later time
(c) Switch to a basal insulin
b) Dawn phenomenon

CHAPTER 12

(1) Rise in blood glucose level upon


waking during the early morning
hours (usually between 4 AM and 9 AM)
(2) Treatment
(a) Limit or regulate evening snacks
(b) Possibly increase NPH dose or
basal insulin
G. Synthetic amylin analog, pramlintide acetate
(Symlin)
1. Mechanism of action: synthetic analog of
human amylin
a) Amylin, like insulin, is located in pancreatic
beta cells. It is secreted with insulin in
response to food intake.
b) Reduces postprandial glucose
c) Slows gastric emptying
d) Decreases food intake
e) Increases satiety
2. Indications
a) Type 1 and type 2 diabetes as an adjunct to
mealtime insulin
3. Usual adult dosage
a) Type 1 diabetes: initially, 15 mcg SC before
meals; may titrate up at 15 mcg increments
(without nausea for 3 days); maintenance:
3060 mcg SC before meals
b) Type 2 diabetes: initially, 60 mcg SC before
meals; may increase dose to 120 mcg SC
before meals (without nausea for three
days)
4. Adverse effects
a) Nausea
b) Hypoglycemia
5. Contraindications and considerations
a) Avoid in gastroparesis and hypoglycemia
unawareness
b) Potential for drug interactions due to
delayed gastric emptying
c) Reduce premeal insulin by 50% when
initiating pramlintide
H. Incretin mimetic agent, exenatide (Byetta)
1. Mechanism of action
a) Stimulates the bodys ability to produce
insulin in response to elevated
concentrations of blood glucose
b) Inhibits the release of glucagon after
meals
c) Slows the rate of gastric emptying
d) Reduces food intake
2. Indications
a) Treatment of type 2 diabetes (adjunct to
metformin, sulfonylurea, or
thiazolidinedione)
3. Usual adult dosage
a) Initially, 5 mcg SC bid given within
60 minutes before morning and evening
meal
b) May increase dose to 10 mcg SC bid after
one month
c) Available in prefilled pens (must refrigerate)
4. Adverse effects
a) Hypoglycemia (more likely when combined
with a sulfonylurea)
b) Nausea

Common Endocrinologic Disorders

141

5. Contraindications and considerations


a) Hypersensitivity to exenatide
b) Potential for drug interactions due to
delayed gastric emptying
c) Has not been studied for use with insulin
d) Pancreatitis
I. Oral agents for diabetes
1. Sulfonylureas
a) Mechanism of action
(1) Stimulates insulin release from pancreatic
beta cells; increases peripheral sensitivity
(2) Inhibits hepatic glucose production;
enhances glucose uptake in muscle
(3) Insulin secretagogues
b) First generation versus second generation(1) Fewer adverse effects with second
generation agents (e.g., glyburide,
glipizide), although patient is still at risk
for hypoglycemia
(2) Second generation (e.g., glyburide,
glipizide, glimepiride) more potent
(3) Comparable efficacy

Comparable Efficacy
Generic (Brand)
First
generation

Second
generation

Acetohexamide
(Dymelor)
Tolbutamide
(Orinase)
Tolazamide
(Tolinase)
Chlorpropamide
(Diabinese)
Glipizide:
Glucotrol
Glucotrol XL
Glyburide:
Micronase,
DiaBeta
Glynase
Glimepiride
(Amaryl)

Adult Daily
Dose Range
2501500 mg
5003000 mg
1001000 mg
100500 mg

2.540 mg
2.520 mg
2.520 mg
1.512 mg
14 mg

c) Indications: management of type 2 diabetes


as monotherapy; also combined with other
antidiabetic medications if needed (e.g.,
metformin, insulin)
d) Usual adult dosage
e) Adverse effects
(1) Hypoglycemia
(2) Nausea/vomiting
(3) Weight gain
(4) Rash
(5) Dyspepsia
(6) Hematologic reactions
f) Contraindications and considerations
(1) Hypersensitivity
(2) Type 1 diabetes
(3) Avoid alcohol

142

SECTION II

PHARMACOTHERAPY IN PRACTICE

2. Biguanides: Metformin (Glucophage,


Glucophage XR, Fortamet, Glumetza, Riomet)
a) Mechanism of action
(1) Inhibit gluconeogenesis and
glycogenolysis
(2) Improve insulin sensitivity
(3) Does not stimulate insulin secretion;
insulin sensitizers
b) Indications
(1) Management of type 2 diabetes as
monotherapy or in combination with
sulfonylurea
c) Usual adult dosage
(1) Initially, 500 mg daily for 710 days.
(2) Standard dose 500 mg bid with meals
(3) May increase at 1- or 2-week intervals by
500 mg if needed
(4) Maximum dose: 2550 mg/day for younger
adults; pediatric and elderly patients
should receive lower maximum daily
doses.
d) Adverse effects
(1) Metallic taste
(2) Abdominal discomfort/cramping
(3) Diarrhea
(4) Nausea/vomiting
(5) Decrease vitamin B12 levels
(6) Lactic acidosis
e) Contraindications
(1) Avoid in patients with renal dysfunction
(SCr >1.5 mg/dL for men and >1.4 for
women)
(2) Hypersensitivity
(3) History of lactic acidosis
(4) Pharmacologically treated heart failure
(5) Radiologic contrast procedures (use of
contrast increases risk for renal
dysfunction and lactic acidosis).
Discontinue metformin 48 hours before
and after procedure.
(6) Alcoholism (especially frequent binge
drinking)
3. Thiazolidinediones, pioglitazone (Actos),
rosiglitazone (Avandia)
a) Mechanism of action
(1) Increases peripheral glucose utilization
(2) Decreases hepatic glucose production
(3) Insulin sensitizer and consequently
reduces insulin secretion
b) Indications
(1) Management of type 2 diabetes as
monotherapy or in combination with
sulfonylurea, metformin, or insulin
c) Usual adult dosage
(1) Pioglitazone: initially, 15 or 30 mg daily;
may increase at 8- or 12-week intervals;
maximum 45 mg daily
(2) Rosiglitazone: initially, 4 mg daily or
in divided doses; may increase at
8- or 12-week intervals; maximum 8 mg
daily
d) Adverse effects
(1) Edema
(2) Weight gain

(3) Anemia
(4) Cardiovascular event (e.g., heart failure,
heart attack risk may be increased with
rosiglitazone)
(5) Hepatic events (liver damage)
(a) Monitor LFT
(6) Potential increased fracture risk (hands,
feet) in women with long-term use
e) Contraindications and considerations
(1) Avoid in patients with congestive heart
failure (CHF) or liver disease
4. Meglitinides, repaglinide (Prandin), nateglinide
(Starlix)
a) Mechanism of action
(1) Similar to sulfonylureas
(2) Stimulates insulin release from beta cells
in a glucose-dependent manner
(3) Insulin secretagogues
b) Indications
(1) Management of type 2 diabetes as
monotherapy or in combination with
metformin or thiazolidinedione
c) Usual adult dosage
(1) Repaglinide: If patients have HbA1c <8%
or are nave: 0.5 mg before meals. If they
have been previously treated with
HbA1c >8%, 12 mg before meals may be
used. Maximum dose 16 mg daily
(2) Nateglinide: Initially, 120 mg tid before
meals; maintenance 120 mg tid before
meals; patients near goal HbA1c may use
60 mg tid
(3) For both: Doses should be skipped if a
meal is skipped
d) Adverse effects
(1) Hypoglycemia
(2) GI upset
(3) Headache
(4) Weight gain
(5) Flu-like symptoms
e) Contraindications and considerations
(1) Type 1 diabetes or for the treatment of
diabetic ketoacidosis (DKA)
5. Alpha glucosidase inhibitors, acarbose
(Precose), miglitol (Glyset)
a) Mechanism of action
(1) Competitive inhibition of
disaccharidases and pancreatic
enzymes
(2) Delays intestinal absorption of
carbohydrates (starch blockers)
b) Indications
(1) Management of type 2 diabetes as
monotherapy or in combination with
sulfonylurea, metformin, or insulin
c) Usual adult dosage
(1) Initially, 25 mg daily with the first bite of
main meal
(2) May titrate up at 2-week intervals
(3) Maximum 100 mg TID with main meals
(4) For both: Dose should be skipped if meal
is skipped
d) Adverse effects
(1) Flatulence

CHAPTER 12

(2) Abdominal cramps


(3) Diarrhea
(4) Borborygmus (stomach rumbling
sounds)
e) Contraindications
(1) Inflammatory bowel disease (IBD)
(2) Intestinal obstruction
6. Dipeptidyl peptidase-4 (DPP-4) inhibitors:
sitagliptin phosphate (Januvia)
a) Mechanism of action
(1) Blocks dipeptidyl peptidase IV (DPP-4),
results in increased insulin release after
meals and when glucose levels are high
b) Indications
(1) Monotherapy or in combination with
other hypoglycemic agents for type
2 diabetes
c) Usual adult dosage
(1) 100 mg once daily with or without food
d) Adverse effects
(1) Nasopharyngitis
(2) Upper respiratory tract infection
(3) Headache
e) Contraindications and considerations
(1) Type 1 diabetes or for the treatment of
diabetic ketoacidosis (DKA)
J. Complications of diabetes
1. Acute
a) Hyperglycemia
b) Hypoglycemia
c) Diabetic ketoacidosis (DKA)
(1) Characterized by high levels of ketones
in the blood
(2) Signs and symptoms
(a) Loss of appetite
(b) Nausea
(c) Vomiting
(d) Fever
(e) Stomach pain
(f) A sweet, fruity smell on the breath,
especially if the blood sugar level has
been consistently greater than
250 mg/dL
(3) More common in type 1 diabetes than
type 2
(4) Treated with insulin therapy (typically
therapy is begun as an insulin infusion in
intensive care setting) and intravenous
fluids
2. Microvascular complications
a) Diabetic neuropathy (nerve damage caused
by prolonged hyperglycemia, often
occurring in feet and legs)
(1) Peripheral neuropathy
(2) Autonomic neuropathy
b) Diabetic retinopathy (a leading cause of
blindness in the United States)
c) Diabetic nephropathy (kidney damage,
nephrons lose filtering capacity, may lead to
kidney failure and need for dialysis or
transplant
3. Macrovascular complications
a) Hyperlipidemia

Common Endocrinologic Disorders

143

b) Hypertension
c) Cardiovascular disease, atherosclerosis
d) Stroke
4. Other complications
a) Increased risk for skin and skin structure
infection (e.g., diabetic foot ulcer)
b) Gum disease; oral health complications
K. Patient education
1. Diet
2. Exercise
3. Home blood glucose monitoring
4. Action plan for hypo- and hyperglycemia
5. Insulin administration; administration and
timing of other antidiabetic medications
6. Complications and prevention of diabetes
7. Eye care
8. Dental care
9. Foot care
II. Thyroid Disorders
Thyroid disorders are among the most common
medical endocrine conditions but, because their
symptoms often appear gradually over time, they are
commonly misdiagnosed. There are two main types of
thyroid disease: hyperthyroidism, or too much thyroid
hormone, and hypothyroidism, or too little thyroid
hormone.
The thyroid produces hormones, called thyroxine (T4)
and triiodothyronine (T3), which affect the bodys
metabolism and energy level. T3 is the short-acting and
more potent of the two hormones. Thyroid hormone is
also produced in response to thyroid stimulating
hormone (TSH, also known as thyrotropin) secreted by
the pituitary gland.
A. Hypothyroidism occurs when the thyroid gland
does not produce enough thyroid hormone.
1. Hashimoto thyroiditis
a) Most common type
b) Inflammation of thyroid gland (not caused
by infection)
c) Occurs when the individuals immune
system attacks the thyroid gland, causing
low levels of thyroid hormone
d) Exhibits low plasma free T4 and elevated
TSH levels
2. Signs and symptoms
a) Cold intolerance
b) Fatigue
c) Somnolence
d) Constipation
e) Menorrhagia
f) Myalgia
g) Hoarseness
h) Gland enlargement
i) Bradycardia
j) Edema
k) Dry skin
l) Weight gain
3. Treatment
a) Thyroid replacement hormones
(1) Levothyroxine (T4) (Synthroid,
Levothroid, Levoxyl, others)
(a) Typical adult maintenance dose after
titration: 100120 mcg PO daily as a

144

SECTION II

PHARMACOTHERAPY IN PRACTICE

single dose 30 minutes before


breakfast, given with plenty of plain
water
(i) Adjust dose in the elderly and in
patients with coronary artery
disease
(ii) Initial dose in elderly 25 mcg per
day versus the initial dose for
younger adults, which is
typically 50 mcg per day
(iii) Those with cardiac disease also
start at 25 mcg daily
(b) Highly protein bound
(c) Precautions
(i) Long-term use has been
associated with increased bone
reabsorption and decreased
bone density
(d) Drug interactions
(i) Antacids, calcium, or iron
supplements should not be taken
within four hours of
levothyroxine dose; may
decrease T4 absorption
(ii) Warfarin effects are enhanced
by levothyroxine
(iii) Digoxin levels may be reduced
by levothyroxine
(2) Liothyronine (T3) (Cytomel, Triostat)
(a) Adult dose: 25 mcg PO qd
(3) Liotrix (T4 and T3, 4:1 ratio) (Thyrolar)
(a) Adult dose: 60120 mg PO qd
(4) Desiccated thyroid, variable T4 and T3
content due to animal gland sourcing
(Armour Thyroid, Naturethroid,
Westhyroid)
(a) Adult dose: 60120 mg PO qd
B. Hyperthyroidism (thyrotoxicosis): occurs when
the thyroid gland produces too much thyroxine.
As a result, the individuals metabolism increases
dramatically, leading to weight loss and irregular
heartbeat.
1. Graves disease
a) Most common cause
b) Malfunction in the bodys immune system
releases abnormal antibodies that mimic
thyroid-stimulating hormone (TSH)
c) Thyroid hormone factories work overtime
and produce an excess of thyroid hormone
d) Exhibits elevated T4 and subnormal TSH
levels
e) Can lead to thyroid storm: a life-threatening
and sudden exacerbation of symptoms of
thyrotoxicosis
(1) Characterized by fever, tachycardia,
frank diarrhea, delirium, and coma
(2) Treatment: antipyretic (not aspirin);
antithyroid drug plus Lugol solution
1 hour later; beta blockers
2. Signs and symptoms
a) Sudden and unexplained weight loss
b) Increased or irregular heartbeat
c) Nervousness

d)
e)
f)
g)
h)
i)
j)
k)
l)
m)
n)

Irritability
Tremors (especially in the hands)
Increased sweating
Abnormal menstruation
Increased sensitivity to warmth
More frequent bowel movements
Enlarged thyroid gland (goiter)
Fatigue
Difficulty sleeping
Muscle weakness
Inability to close the eyelid (eyelid
retraction)
3. Treatment
a) Antithyroid drugs
(1) Methimazole (Tapazole)
(a) Adult dose: 540 mg QD
(b) Favored over propylthiouracil (PTU)
due to longer half-life, which allows
for once a day dosing
(c) More potent than PTU
(2) Propylthiouracil (PTU)
(a) Adult dose: Initially, 300 mg QD, then
usually 100150 mg daily
(b) Although both drugs cross the
placenta, the drug of choice in
pregnant patient is PTU because it
crosses less
(3) Strong iodine solution (Lugols
solution)
(a) Adult dose: 0.10.3 mL (35 gtts) PO
TID
(4) Saturated solution of potassium iodide
(SSKI)
(a) Usual adult dose: 15 gtts PO TID in
water or juice
b) Surgery
c) Radioactive iodine
(1) Sodium iodide-131 (131I), the agent of
choice for Graves disease
(2) Most will require thyroid hormone
supplementation after radioactive iodine
treatment

PATIENT PROFILE
Patient Initials: CC
Sex: Female
Age: 22 years
Height: 50 400
Weight: 68 kg
Race: Latin American
Allergies: No known drug allergies (NKDA)
Chief Complaint:
CC is a 22-year-old woman with a history of gestational
diabetes; she has one child, now 2 years old. She presents
to the pharmacist clinic service for the first time because
her family doctor has just told her that she now has type
2 diabetes. My blood sugars were high on two tests, she
explains, but I feel great, and I am young. Why do I have
to take medications? Cant I just exercise and lose some
weight?

CHAPTER 12

Exercise: Began walking program last week with her


mother, who also has type 2 diabetes and is overweight
Medications:
Multivitamin once daily
New prescription: Metformin 500 mg PO twice daily
Other: Wears eyeglasses for reading
Laboratory:
Blood glucose: 220 mg/dL, nonfasting
Blood glucose: 140 mg/dL, fasting
Hemoglobin A1c (HbA1c): 8.6%

2.

The pharmacist encourages CCs new exercise


routine and weight loss goals. These plans are
endorsed by her family doctor. Exercise may improve
insulin sensitivity, promote weight reduction, and
improve overall health. Weight reduction can lower
the need for medications in some patients. In addition
to exercise, what other preventative options should
be recommended for CC at this time?
I. Checking with her doctor regarding her
cholesterol levels
II. Taking a baby aspirin (aspirin 81 mg) daily to
prevent heart disease
III. Performing daily foot self-examinations
IV. Keeping regularly scheduled ophthalmic exams
a. I and II
b. III and IV
c. I, III, and IV
d. All of the above
Answer: c. All patients with diabetes should be
screened for lipid disorders because early
management can help prevent macrovascular
complications, such as myocardial infarction (MI).
Current evidence suggests that aspirin is ONLY

145

recommended for patients with diabetes with known


heart disease and as primary prevention ONLY in
patients with diabetes older than 30 years old with
heart disease risk factors. CC is 22 years of age and is
in an age bracket where insufficient benefit and risk
information is available regarding preventative
aspirin therapy. Daily self-examinations of the feet for
cracks, callus formation, ulcers, and other issues will
help avoid serious foot problems. Routine eye exams
are recommended for any patient with diabetes with
known visual difficulty; how often they are performed
depends on age and known visual problems. Annual
eye exams are recommended for those older than 30
years of age without any current visual difficulties.
Younger patients should have routine exams at least
every 5 years or more frequently if they already have
visual impairment or changes.

Social History:
Tobacco use: None
Alcohol use: A few glasses of wine per week, usually with
dinner

PATIENT PROFILE QUESTIONS


1. After discussion with the patient, it is clear that CC
has little understanding of her new diagnosis and will
need extensive diabetic education. When discussing
blood sugar and HbA1c tests, which of the following
would a pharmacist state as CCs HbA1c treatment
goal?
a. <6.5%
b. <8%
c. <7.5%
d. <7%
Answer: d. Based on well-known studies such as the
Diabetes Control and Complications Trial (DCCT), a
goal HbA1c of less than 7% reduces the risk of
microvascular complications, such as diabetes-related
nephropathy and retinopathy. Higher HbA1c levels
increase the risk of chronic complications of diabetes.
Some organizations recommend more aggressive goals
(e.g., HbA1c <6.5%), but aggressive goals expose a
patient to a greater risk of severe hypoglycemia.

Common Endocrinologic Disorders

3.

CC will begin the metformin prescription as


prescribed. During discussion with CC, the
pharmacist should include which of the following in
the counseling about the new prescription?
I. Metformin is often a drug of choice when type
2 diabetes is first diagnosed. It is effective at
lowering blood sugar, does not cause weight
gain, and does not cause low blood sugar when
used alone.
II. Common side effects that usually decrease in a
few weeks include nausea or reduced appetite.
III. CC should avoid binge drinking of alcohol to
avoid lactic acidosis, a serious but rare side
effect that can harm the kidneys.
IV. If CC follows her recommended diet and exercise
plan, maintains a recommended body weight,
and takes the metformin as prescribed, she can
expect her HbA1c to drop about 1.5% with the
medication.
a. I only
b. II only
c. I, II, and III
d. All of the above
Answer: d. Diabetes treatment guidelines place
metformin monotherapy as first-line treatment for
healthy, adults newly diagnosed with type 2 diabetes
who have no other contraindications to metformin
use. Common side effects are nausea, diarrhea,
reduced appetite, and sometimes a metallic-like taste.
These usually go away in a few weeks. Binge drinking
of alcohol can be a risk factor for lactic acidosis and is
often an important counseling point in a young patient
with an active social life. Metformin will reduce HbA1c,
will not cause weight gain, and can help CC reach her
optimal health goals. If she is educated and adherent,
she may avoid the need for additional medications.

REVIEW QUESTIONS
(Answers and Rationales on page 356.)
1. Lipohypertrophy in patients with diabetes is due to
which of the following?
a. Repeated injections into the same site
b. Injections into fat-rich tissue

146

SECTION II

c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Too-rapid insulin injection


Hypersensitivity to insulin
Hypersensitivity to insulin vehicle

2. Which of the following is true of insulin?


a. It is secreted by pancreatic alpha cells
b. It promotes peripheral glucose uptake and
utilization
c. It inhibits hepatic gluconeogenesis
d. a and b
e. b and c
3. Which of the following insulin preparations is
available as a recombinant human analog?
a. Insulin lispro
b. Lente insulin
c. Regular insulin
d. None of the above
e. All of the above
4. Which of the following steroids have the longest
duration of action?
I. Betamethasone
II. Dexamethasone
II. Hydrocortisone
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

5. Which of the following conditions increases the risk


of amputations in diabetics?
a. Peripheral Neuropathy
b. Peripheral Vascular Disease
c. Erythema
d. All of the above
e. None of the above
6. Which of the following is used for treatment of
thyroid storm:
I. levothyroxine
II. hydrocortisone
III. propylthiouracil
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

a.
b.
c.
d.
e.

Serum creatinine, blood urea nitrogen,


potassium, and sodium
Serum creatinine and blood urea nitrogen
Urine protein and sodium
Urine protein, sodium, and glucose
Urine protein, sodium, glucose, and potassium

9. Of the following patients, which is most likely to


experience an adverse drug reaction?
a. 30-year-old man taking chlorpropamide and
atenolol
b. 40-year-old woman taking pioglitazone with a
serum BUN of 17 mg/dL
c. 30-year-old woman taking acarbose with an ALT
of 80 IU/L and AST of 90 IU/L
d. 40-year-old man taking lisinopril and pioglitazone
e. 40-year-old woman taking lisinopril with an ALT
of 30 IU/L and AST of 30 IU/L
10. Androgens are associated with which of the following
adverse effects?
a. Priapism
d. Jaundice
c. Gynecomastia
d. Urinary retention
e. All of the above
11. Sulfonylureas are associated with which of the
following adverse effects?
a. Jaundice
b. Photosensitivity
c. Nausea
d. a and b
e. a, b, and c
12. Which of the following statements about insulin is true?
a. It is secreted by pancreatic alpha cells,
b. It promotes peripheral glucose uptake and
utilization,
c. It inhibits hepatic gluconeogenesis,
d. a and b
e. b and c
13. Which of the following is a useful feature to
differentiate cholinestase inhibitor overdose with
myasthenia gravis exacerbation?
a. Sweating
b. Weakness
c. Fasciculations
d. Salivation
e. All of the above

7. Which of the following classes of drugs requires


periodic monitoring of liver function?
a. Thiazolidinedione
b. Biguanide
c. Meglitinide
d. Sulfonylurea
e. None of these drugs requires monitoring of liver
function

14. Which of the following agents can cause the


syndrome of inappropriate secretion of antidiuretic
hormone (SIADH)?
a. Fluoxetine
b. Vincristine
d. MDMA
d. Risperidone
e. All of the above

8. Which of the following should be monitored in


patients with diabetes treated with ACE inhibitors?

15. Which of the following is TRUE about sulfonylureas?


a. Tolazamide is a second generation agent

CHAPTER 12

b.
c.
d.
e.

Chlorpropamide is a first generation agent


Safe to use during pregnancy
a and b
b and c

16. What is the standard daily dose of glyburide?


a. 1.2520 mg/day
b. 2080 mg/day
c. 100400 mg/day
d. 200800 mg/day
e. 5002000 mg/day
17. Patients taking chlorpropamide should be counseled
to avoid which of the following?
a. Cheese
b. Vitamin K
c. Milk
d. Alcohol
e. Acetaminophen
18. Which of the following are responsible for inhibiting
insulin release?
a. Secretin
b. Gastrin
c. Somatostatin
d. Cholecystokinin
e. All of the above
19. Which of the following drugs increase pancreatic
insulin secretion?
a. Glipizide
b. Metformin
c. Acarbose
d. All of the above
e. None of the above
20. Oral medications to treat type 2 diabetes do which of
the following?
I. Reduce insulin resistance
II. Stimulate endogenous insulin
III. Delay carbohydrate absorption
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

21. Which of the following is/are the active ingredient(s)


of Avandamet?
a. Rosiglitazone
b. Glipizide
c. Metformin
d. a and b
e. a and c
22. CO is a taking Precose (acarbose) 100 mg PO tid.
Which of the following should be monitored?
a. AST
b. CK
c. PT
d. INR
e. CK

Common Endocrinologic Disorders

147

23. Glyset is a drug that inhibits:


a. alpha glucosidase
b. angiotensin-converting enzyme (ACE)
c. protease
d. acetylcholinesterase
e. topoisomerase
24. Which of the following is NOT an appropriate
treatment for hyperthyroidism?
a. Propranolol
b. Corticosteroids
c. Bromocriptine
d. Propylthiouracil
e. Lugol solution
25. Which of the following is a side effect of biosynthetic
growth hormone?
a. Hepatitis B
b. Antibody formation
c. Creutzfeldt-Jakob disease
d. HIV transmission
e. Hypoglycemia
26. Which of the following statements about insulin is true?
a. It is reabsorbed in the renal tubules.
b. It is metabolized in the liver.
c. It has a half-life of less than 10 minutes.
d. a and b
e. a, b, and c
27. Which of the following causes increased insulin
activity after glucose consumption?
a. Gastrin
b. Secretin
c. Gastric inhibitory polypeptide (GIP)
d. a and b
e. a, b, and c
28. Which of the following is an effect of insulin?
a. Inhibition of hormone sensitive lipase
b. Increased glycogenolysis
c. Increased CNS glucose uptake
d. a and b
e. a and c
29. Insulin ultralente:
a. has an onset of action in 12 hours.
b. has peak activity at 46 hours.
c. has a duration of action of 1824 hours.
d. All of the above
e. None of the above
30. Which of the following is NOT a side effect of
chlorpropamide?
a. Hypoglycemia
b. Rash
c. Lactic acidosis
d. Syndrome of inappropriate antidiuretic hormone
hypersecretion (SIADH)
e. Disulfiram-type reaction
31. Which of the following is an effect of sulfonylureas?
a. Decreased hepatic gluconeogenesis

148

SECTION II

b.
c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Increased peripheral tissue insulin sensitivity


Increased insulin-receptor binding
a and b
a, b, and c

32. Which of the following may cause SIADH?


a. Acetohexamide
b. Chlorpropamide
c. Glipizide
d. Tolazamide
33. Which of the following statements about oral
hypoglycemic agents is true?
a. Second-generation agents have less affinity for
albumin.
b. First-generation agents are more potent due to
larger R substituents.
c. First- and second-generation hypoglycemic
agents are sulfonylureas.
d. a and b
e. a and c
34. Which of the following is NOT a mechanism of oral
sulfonylureas?
a. Regeneration of pancreatic beta cells
b. Correction of post receptor defects
c. Increased tissue insulin sensitivity
d. Decreased hepatic gluconeogenesis
e. All of the above are mechanisms of
sulfonylureas
35. Which of the following is the correct insulin: onset of
action pair?
a. Insulin Lispro: 13 hrs
b. Regular: 1015 min
c. Insulin glargine: 0.51 hr
d. All of the above.
e. None of the above.
36. Effects of insulin include:
a. increased glycogenolysis.
b. increased glycosuria.
c. increased conversion of protein to glucose.
d. increased transport of glucose into the central
nervous system.
e. inhibition of hormone sensitive lipase.
37. Which of the following statements is correct?
a. Lente insulin has an initial onset of 12 hours,
a peak at 614 hours, and a duration of 24 or
more hours.
b. Regular insulin has an initial onset of 30 minutes
to 1 hour, a peak at 24 hours, and a duration of
57 hours.
c. NPH insulin has an initial onset at 1015 minutes,
a peak at 24 hours, and a duration of
35 hours.
d. a and b
e. a and c
38. Which of the following may occur with
methimazole?
a. Pruritus

b.
c.
d.
e.

Neutropenia
Decreases peroxidase activity
a and c
a, b, and c

39. What is the standard recommended dose range of


glyburide?
a. 0.52 mg/day
b. 1.2520 mg/day
c. 50100 mg/day
d. 200 mg/day
e. 2001000 mg/day
40. Patients taking chlorpropamide should avoid
products containing:
a. acetaminophen.
b. ethanol.
c. vitamin A.
d. penicillins.
e. milk products.
41. Which of the following pregnant patients does NOT
need to undergo a 50 g glucose screening test during
weeks 2428 of pregnancy?
a. 30-year-old Latin woman with a negative screen
at 15 weeks
b. 30-year-old Pacific Island woman who has a body
mass index of 30 and no family history of diabetes
c. 20-year-old African American woman with a body
mass index of 22 and no family history of diabetes
d. 20-year-old Caucasian woman with normal body
weight
e. 20-year-old Latin woman with a body mass index
of 30 and no family history of diabetes
42. A 22-year-old patient is admitted to the hospital with
diabetic ketoacidosis (DKA). What is the most
appropriate treatment to decrease cerebral edema in
this patient?
a. Sodium bicarbonate
b. Insulin
c. Methylprednisolone
d. Mannitol
e. None of the above
43. Normal blood glucose for a fasting patient is between:
a. 2040 mg/dl
b. 6080 mg/dl
c. 80120 mg/dl
d. 180200 mg/dl
e. 220240 mg/dl
Read the following case study and answer the questions
that follow.
A 55-year-old man goes to the physician for his annual
check-up. He has a medical history significant for obesity,
hypertension, gout, and hypercholesterolemia. He reports
that 1 week earlier, he attended a free health clinic at
his place of work where his random blood glucose was
found to be 220 mg/dL. On examination, he has decreased
hair growth over the lower legs, decreased sensation
over the feet and ankles, and flame hemorrhages on

CHAPTER 12

opthalmoscopic examination. Laboratory diagnosis on a


fasting blood sample shows a blood glucose of 175 mg/dL.
His physician diagnoses DM.
44. Which of the following is NOT a risk factor for DM
type 2?
a. Poor diet
b. Obesity
c. High fiber intake
d. Family history
e. Sedentary lifestyle
45. Which of the following is the most appropriate
dosage and medication for the initial treatment of
DM type 2?
a. Pioglitazone, 500 mg once per day
b. Metformin, 500 mg twice per day
c. Insulin glargine, 15 units once per day
d. Glipizide, 5 mg once per day
e. Repaglinide, 5 mg before each meal
46. Metformin:
a. may cause diarrhea.
b. is safe to use in diabetic ketoacidosis.
c. decreases gluconeogenesis.
d. a and b
e. a and c

a.
b.
c.
d.
e.

Common Endocrinologic Disorders

149

I only
III only
I and II only
II and III only
I, II, and III

51. Diabinese (chlorpropamide):


I. Is a sulfonylurea
II. Has a prolonged duration of action
III. May cause disulfiram-like reactions
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

52. Avandia:
I. Improves insulin secretion
II. Improves insulin sensitivity
III. Inhibits hepatic glucose production
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

47. Glipizide:
a. enhances insulin release.
b. enhances peripheral insulin sensitivity.
c. inhibits hepatic glucose production.
d. a and b
e. a, b, and c

53. Humalog:
a. Has a rapid onset of action
b. Should be administered subcutaneously
c. Should be given within 15 minutes of a meal
d. Is insulin Lispro
e. All of the above

48. True or False: Pioglitazone does not require dose


adjustments for renal impairment.
a. True
b. False

54. Which of the following is a rare but serious side effect


of Glucophage?
a. Pulmonary fibrosis
b. Neurotoxicity
c. Lactic acidosis
d. Pulmonary embolism
e. Infertility

49. Pioglitazone:
a. may cause myalgia.
b. should be taken on an empty stomach.
c. is poorly protein bound in circulation.
d. is excreted predominately (>90%) in the urine.
e. All of the above
50. Hemoglobin A1c (HbA1c):
I. Represents the average blood glucose for
3 months
II. Helps determine glycemic control
III. Should be more than 6%

55. Which of the following insulin preparations has a


prolonged duration of action?
a. Lantus
b. Humalog
c. Humulin R
d. NovoLog
e. All of the above

..................................................

Gastrointestinal Disorders

13
CHAPTER

...................................................................................................................................................................

I.

Gastrointestinal System Anatomy


A. Mouth
B. Esophagus
C. Stomach
D. Gallbladder
E. Pancreas
F. Small bowel
G. Large bowel
H. Rectum
II. Peptic Ulcer Disease
A peptic ulcer is a sore in the lining of the stomach,
esophagus, or the first portion of the small intestine.
Peptic ulcers may also be referred to as an ulcer.
A. Pathology
1. Peptic ulcers occur when the digestive juices that
help food digest damage the walls of the stomach
or duodenum. The most common cause is
infection with a bacterium called Helicobacter
pylori, or H. pylori. Another cause is the long-term
use of nonsteroidal anti-inflammatory drugs
(NSAID) such as aspirin and ibuprofen (e.g.,
Motrin, Advil) (Table 13-1). Spicy foods do not
cause ulcers, but can aggravate them and make
them worse.
B. Risk factors
1. H. pylori
a) Sex (men more than women)
b) Age (risk increases with age)
c) Smoking
d) Caffeine consumption
e) Stress
f) Excessive alcohol consumption
g) Other conditions
(1) Achalasia (failure of pyloric sphincter to
relax)
2. NSAID-induced
a) Presence of H. pylori
b) Corticosteroid use
c) Age (older than 70 years old)
d) Anticoagulant use (the use of anticoagulants
increases risk for NSAID-induced ulcer bleed)
e) Dose of NSAID
f) Use of multiple NSAIDs
g) Previous uncomplicated ulcer or ulcerrelated complication
C. Signs and symptoms
1. Burning pain is the most common peptic ulcer
symptom. The pain is caused by the ulcer and is
aggravated by stomach acid contacting the
ulcerated area. The pain may last from a few
150

minutes to many hours and may flare up at


night. Peptic ulcers also tend to be worse when
the stomach is empty.
D. Prevention
1. Smoking cessation
2. Decreasing alcohol consumption
3. Controlling acid reflux
4. Dietary modifications (more whole grains,
vegetables, fresh fruit; less red meat and fatty
foods)
E. Treatment
1. Because many ulcers are caused by H. pylori
bacteria, an approach to peptic ulcer treatment
that eradicates the bacteria and reduces the
level of acid in the digestive system is used. The
result of the treatment is pain relief and ulcer
healing.
2. Histamine H2 antagonists or H2 blockers
a) Mechanism of action: reversible H2
antagonism in gastric parietal cells
(1) Inhibits secretions caused by histamine,
gastrin, and muscarinic agonists
(2) Reduces the amount of hydrochloric
acid released into the digestive tract
(3) Examples
(a) Cimetidine (Tagamet)
(i) Usual adult dose (oral):
prophylaxis, 400 mg qhs; active
ulcers (short term), 300 mg qid or
800 mg qhs or 400 mg bid for 4 to
8 weeks
(ii) Adverse effects: antiandrogenic
effects (gynecomastia,
impotence), anticholinergic
effects
(iii) Drug interactions: inhibits
cytochrome P-450 (CYP) 1A2,
2C9, 3A4; interacts with many
prescription and nonprescription
drugs; classic drug interactions
include narrow-therapeutic index
drugs (e.g., theophylline,
warfarin, phenytoin)
(b) Ranitidine (Zantac)
(i) Usual adult dose (oral): 150 mg
bid or 300 mg qhs
(ii) Adverse effects: well tolerated
(iii) Drug interactions: drugs that
require acid for absorption (e.g.,
ketoconazole)

CHAPTER 13

Table 13-1

Characteristics of H. pylori versus


NSAID-induced ulcers

H. pylori
Direct mucosal damage
caused by
hypergastrinemia
Ulcers are superficial;
chronically inflamed
Symptoms: epigastric
pain (may be
nocturnal), nausea,
indigestion, fatigue

Nonsteroidal antiinflammatory drugs (NSAIDs)


Direct mucosal damage
associated with
prostaslandin
inhibition
Ulcers are deep; no
inflammation
Patients are usually
asymptomatic;
complications cause
bleeding perforation

(c) Famotidine (Pepcid)


(i) Usual adult dose (oral): 20 mg qhs
(ii) Adverse effects: well tolerated
(iii) Drug interactions: drugs that
require acid for absorption (e.g.,
ketoconazole)
(d) Nizatidine (Axid)
(i) Usual adult dose (oral): 150 mg
bid or 300 mg qhs
(ii) Adverse effects: well tolerated
(iii) Drug interactions: Drugs that
require acid for absorption (e.g.,
ketoconazole)
3. Antibiotics
a) A combination of antibiotics is usually used
to treat H. pylori infections because one
antibiotic alone is not usually sufficient to
eradicate the organism. (See Box 13-1)
b) Commonly prescribed antibiotics for
treatment of H. pylori include amoxicillin
(Amoxil), clarithromycin (Biaxin), and
metronidazole (Flagyl).
4. Antacids
a) Mechanism of action
(1) Neutralize gastric acid
(2) Inhibit proteolytic activity of pepsin
(3) Raise pH
(4) Do not absorb acid or coat the mucosal
lining
b) Adverse effects
(1) Diarrhea (magnesium)
(2) Constipation (aluminum)
(3) Edema (sodium)
(4) Milk alkali syndrome
c) Drug interactions
(1) Quinolones, tetracyclines, iron salts,
itraconazole, ketoconazole
d) Examples
(1) Calcium carbonate (Tums, Titralac)
(2) Aluminum hydroxide and magnesium
hydroxide combinations (Mylanta,
Maalox)
(3) Aluminum hydroxide alone (Alternagel)

Gastrointestinal Disorders

151

e) Antacids should be taken 1 hour before or


2 hours after taking other prescribed
medications.
5. Proton pump inhibitors (PPI)
a) Superior to H2 blockers in the healing,
recurrence, and prevention of ulcers. Used
preferentially with antibiotics in H. pylori
eradication and ulcer treatment regimens.
b) Mechanism of action
(1) Inhibits H/K-ATPase enzyme system
at the gastric parietal cell thereby
blocking the last step of acid
production
c) Adverse effects and precautions
(1) All PPI are generally well tolerated.
Occasionally, they may cause nausea,
diarrhea, headache or serious allergictype reactions.
(2) All PPI should be taken 30 minutes before
eating (i.e., on an empty stomach).
d) Drug interactions
(1) Omeprazole, lansoprazole,
esomeprazole: substrates and inhibitors
of CYP450 3A4 phenytoin, warfarin
(2) Rabeprazole, esomeprazole: substrates
and inhibitors of CYP450 2C19
(3) All PPI may decrease the absorption of
azole antifungals, protease inhibitors,
iron salts.
e) Usual adult dose (oral)
(1) Omeprazole (Prilosec): 20 mg qd
(2) Lansoprazole (Prevacid): 15 mg qd
(3) Rabeprazole (Aciphex): 20 mg qd
(4) Esomeprazole (Nexium): 40 mg qd
(5) Pantoprozole (Protonix): 20 mg qd
6. Cytoprotective agents
a) Sucralfate (Carafate)
(1) Mechanism of action
(a) As an aluminum salt of sulfated
sucrose, the aluminum ion splits
away in the acid of gastric juice,
which leaves a polar ion that is not
absorbed. A viscous, adhesive
substance is formed and acts locally
to protect the site against acid,
pepsin, and bile salts.
(2) Adverse effects: well tolerated;
constipation
(a) Caution in patients with renal failure
(3) Drug interactions
(a) Sucralfate may decrease the
absorption of azole antifungal
agents, quinolones, phenytoin, and
phosphate supplements
(b) Doses to be separated by 2 hours
from sucralfate to avoid binding
interactions
(4) Usual adult dose (oral)
(a) 1 g bid (maintenance/prophylaxis)
(b) 1 g qid or 2 g bid (treatment)
b) Misoprostol (Cytotec)
(1) Mechanism of action
(a) Synthetic prostaglandin E analog

152

SECTION II

Box 13-1



PHARMACOTHERAPY IN PRACTICE

Treatment Regimens for H. Pylori

Combination therapy of a proton pump inhibitor (PPI) plus two antibiotics is generally recommended for
treating H. pylori.
Strategies will vary from one practitioner to another, but generally are as follows:

First-Line Treatment
Used for 714 days

Regimen 1

PPI bid

Clarithromycin 500 mg bid

Amoxicillin 1 g bid

Regimen 2

PPI bid

Clarithromycin 500 mg bid

Metronidazole 500 mg bid

First-Line Treatment in Patients with Macrolide Allergy or as Retreatment


Used for 14 days
Can also be used for retreatment




Regimen 1

PPI bid

Amoxicillin 1 g bid

Metronidazole 1 g bid

Second-Line Treatment (or can use biopsy to culture for sensitivities)


Used for 714 days
Can be used as an alternative to first-line therapy but typically is reserved for retreatment (14 days)




Regimen 1

PPI bid

Bismuth subsalicylate
525 mg qid

(b) Antisecretory and mucosalprotecting properties


(2) Adverse effects
(a) Diarrhea (self-limiting; resolves after
8 days)
(b) Abdominal pain
(c) Contraindicated in pregnancy or
women of child-bearing age because
the drug causes strong uterine
contractions and may induce
miscarriage.
(3) Drug interactions: not clinically
significant
(4) Usual adult dose: 100200 mcg PO qid
with food
III. Gastroesophageal Reflux Disease
Gastroesophageal reflux disease (GERD), also called
acid reflux disease, occurs when liquid from the
stomach regurgitates into the esophagus. This liquid
may contain stomach acids and bile. In some cases, the
regurgitated stomach liquid can cause inflammation
(esophagitis), irritation, and damage to the esophagus.
A. Pathology
1. Develops when normal protective mechanisms
of the esophagus begin to fail
2. Gastric acid enters into the distal esophagus,
causing a burning sensation behind the
breastbone, and sometimes leads to
regurgitation of ingested food.
B. Risk factors
1. Tea, coffee, chocolate consumption
2. Tobacco
3. Obesity
4. Over-eating
5. Spicy foods
6. Hiatal hernias (the stomach pushes up through
a hole in the diaphragm muscle)

Tetracycline
500 mg qid

Metronidazole 500
mg qid

7. Abnormally weak contractions of the lower


esophageal sphincter
8. Abnormal emptying of the stomach after a meal
C. Signs and symptoms
1. Heartburn: a burning sensation in the chest that
may spread to the throat
2. Regurgitation
3. Water brash (hypersalivation)
4. Belching
5. Several factors may worsen symptoms of the
condition including spicy foods, fatty foods,
chocolate, caffeine, tomato sauce, carbonated
beverages, mint, alcoholic beverages, large
meals, lying down after eating, some
medications (e.g., sedatives, tranquilizers, or
blood pressure drugs), and cigarette smoking.
D. Complications
1. If GERD persists for a long time it causes
esophagitis, ulceration, bleeding, scar, stricture
formation, and Barretts esophagus
E. Treatment
1. Lifestyle modifications
a) Eating slowly
b) Eating three small meals
c) Weight loss
d) Smoking cessation
e) Sleeping in an upright position
f) Avoiding lying down after eating
2. Mild symptoms
a) Over-the-counter (OTC) antacids
b) OTC H2 blockers
c) OTC PPI
3. Mild refractory
a) Prescription H2 blockers
4. Moderate to severe
a) Prescription PPI
b) Metoclopramide

CHAPTER 13

(1) Mechanism of action


(a) Enhances motility of GI contents
through the upper GI tract
(prokinetic agent)
(2) Adverse effects
(a) Neurologic alterations (e.g.,
confusion)
(b) Dystonic reactions
(3) Drug interactions
(a) Concurrent use with antipsychotic
agents may increase risk of
extrapyramidal symptoms (EPS)
(4) Usual adult dose
(a) 1015 mg/dose PO, maximum of four
times per day, each dose given
30 minutes before meals or food and
at bedtime
IV. Inflammatory Bowel Disease
Inflammatory bowel disease (IBD) refers to two chronic
diseases that cause inflammation of the intestines:
ulcerative colitis and Crohns disease.
A. Etiology
1. The cause of IBD remains unknown. However,
current research indicates that IBD most likely
involves a complex interaction of factors,
including heredity, the immune system, and
antigens in the environment.
B. Pathophysiology (Table 13-2)
C. Complications
1. Toxic megacolon
2. Colon cancer
D. Signs and symptoms
1. The symptoms of these two illnesses are similar,
which often makes it difficult to distinguish
between the two. In fact, about 10% of colitis
(inflamed colon) cases cannot be diagnosed as
either ulcerative colitis or Crohns disease. When
physicians cannot diagnose the specific IBD, the
condition is called indeterminate colitis.
2. IBD causes chronic inflammation in the
gastrointestinal tract and may lead to
complications, such as colon cancer. The most
common symptoms of both ulcerative colitis
Table 13-2

Characteristics of Inflammatory Bowel


Disease
Ulcerative colitis

Crohn disease

Anatomic sites Colon and rectum Any part of the


GI tract
Lesions
Continuous
Discontinuous
and superficial
Depth of
Mucosa and
Transmural
involvement
submucosa
inflammation
inflammation
Pathologic
Polyps
Obstruction due
findings
to inflammation
Perforation
Perianal fistulas

Gastrointestinal Disorders

153

and Crohns disease are diarrhea (ranging from


mild to severe), abdominal pain, decreased
appetite, and weight loss. If the diarrhea is
extreme, it may lead to dehydration, increased
heartbeat, and decreased blood pressure. As
food moves through inflamed areas of the
gastrointestinal tract, it may cause bleeding.
E. Treatment
1. Nonpharmacologic treatment: nutritional support
2. Surgery: for complications (abscess, fistula,
perforation)
3. Pharmacologic therapy
a) Corticosteroids
(1) Reduce inflammation of the
gastrointestinal tract
(2) Oral and rectal therapy used for acute
management only; IV therapy reserved
for severe disease
(3) Adverse effects
(a) Hypertension
(b) Sodium and water retention
(c) Glucose intolerance
(4) Examples and typical adult doses
(a) Rectal
(i) Cortifoam 90 mg qd or bid
(ii) Cortenema 100 mg in 60 mL
applied qhs
(b) Oral
(i) Prednisone 2060 mg qd
(ii) Budesonide (Entocort EC) 9 mg
qAM for maximum 8 weeks for
active episodes (used for
Crohns disease involving the
ileum or ascending colon); a
dose of 6 mg PO qAM may be used
for maintenance therapy for up
to 3 months.
b) Immunosuppressants
(1) Used for severe colitis, steroid dependent
(2) Adverse effects
(a) Bone marrow suppression
(b) Hepatitis
(c) Pancreatitis
(3) Examples and typical adult dose
(a) Azathioprine (Imuran) 75150 mg
PO qd
(b) 6-mercaptopurine (Purinethol)
50100 mg PO qd
(c) Cyclosporine (Neoral or
Sandimmune)
(i) Dose: 4 mg/kg PO per day
(ii) Monitor levels
(iii) Adverse effects: hypertension,
nephrotoxicity, electrolyte
abnormalities
(iv) Drug interactions: major CYP
450 3A4 substrate and inhibitor
c) 5-aminosalicylates
(1) Used for acute management and
maintaining remission
(2) Oral and rectal therapies available
(3) Adverse effects
(a) Nausea/vomiting

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PHARMACOTHERAPY IN PRACTICE

(b) Diarrhea
(c) Malaise
(d) Fever
(e) Headache
(f) Rash
(g) Impairs absorption of folic acid
(h) Contraindicated in patients with
sulfa allergy (suffasalazine only)
(4) Examples and typical adult dose
(a) Mesalamine suppository: 500 mg
rectally qd or bid
(b) Mesalamine enema: 4 g in 60 mL
rectally qhs
(c) Sulfasalazine (Azulfidine): 46 g PO
qd (acute); 24 g qd (chronic)
(d) Olsalazine (Dipentum): 1.53 g PO qd
(acute); 2 g qd (chronic)
(e) Mesalamine (Asacol): 2.44.8 g PO qd
(acute); 1.62.4 g qd (chronic)
(f) Mesalamine (Pentasa): 24 g PO qd
(acute); 12 g (chronic)
d) Antibiotics and typical adult dose
(1) Metronidazole 1020 mg/kg per day PO;
ciprofloxacin 1 g PO qd
(2) Used for perianal fistula
e) Tumor necrosis factor (TNF) blocking
agents, examples
(1) Infliximab (Remicade)
(2) Used for moderate to severe disease and
for perianal fistula
(3) Typical adult dose
(a) 5 mg/kg IV at 0, 2, 6 weeks then every
8 weeks as maintenance
(4) Adverse effects
(a) Infusion-related reactions
(premedicate with antihistamines
and/or corticosteroids)
(b) Abdominal pain
(c) Infection
(d) Development of antinuclear antibodies
(e) Development of new abscess
(f) Contraindicated in heart failure (New
York Heart Association class III/IV)
(5) Drug interactions
(a) May enhance the toxic effects of live
vaccines
(b) May reduce the effect of inactivated
vaccines
V. Irritable Bowel Syndrome
Irritable bowel syndrome (IBS), also called spastic colon,
mucous colitis, spastic colitis, nervous stomach, or
irritable colon, is a long-term condition that is
characterized by abdominal pain, cramping, diarrhea, and
constipation. IBS is a functional bowel disorder because
the bowel appears normal but does not function properly.
A. Pathophysiology
1. Motility disorders of the GI tract
2. Intestinal secretion
3. Visceral hypersensitivity
B. Etiology
1. Although the exact cause of IBS is unknown, it
may be due, at least in part, to poor diet,
neurotransmitter imbalances, and infections.

C. Clinical presentation
1. Constipation predominant
2. Diarrhea predominant
3. Alternating constipation and diarrhea
D. Signs and symptoms
1. In patients with IBS, the muscles of the colon,
sphincters, and pelvis do not contract properly.
As a result, patients experience constipation or
diarrhea. This causes symptoms of abdominal
pain, cramping, bloating, and a sense of
incomplete stool movement. Symptoms may
improve after the patient has a bowel
movement.
E. Treatment
1. Nonpharmacologic
a) Dietary modification
b) Stress management
2. Pharmacologic
a) Constipation predominant IBS
(1) Bulking agents
(a) Psyllium (e.g., Metamucil, Konsyl)
(2) Tegaserod (Zelnorm)
(a) Selective serotonin 5-HT4 agonist
(b) Withdrawn from the market due to
increased risk of heart attack and
stroke
(3) Lubiprostone (Amitiza)
(a) Prostagland in E1 derivative, cloride
channel activator
(b) Usual adult dose: 8 mcg PO twice
daily with food
(4) Osmotic, stimulant, and emollient
laxatives may be used, but not routinely
b) Diarrhea-predominant IBS
(1) Antidiarrheals and typical adult dose
(a) Loperamide (Imodium)
(i) Dose: 4 mg followed by 2-mg PO
after each loose stool. Maximum
of 16 mg daily
(b) Diphenoxylate/atropine (Lomotil)
(i) Dose: 5 mg PO four times daily as
needed
(2) Alosetron (Lotronex)
(a) Selective serotonin 5-HT3 antagonist
(b) Used for women who fail
conventional therapy
(c) Withdrawn from the market in 2000
due to reported serious GI adverse
effects (obstruction, perforation,
impaction, toxic megacolon), but in
2002 became available again under a
risk-management program
(d) Typical adult dose: 0.5 mg1 mg PO
twice daily
c) Antispasmodics
(1) Used in patients with abdominal pain
(2) Examples: hyoscyamine (Levsin or
Levsinex), dicyclomine (Bentyl), and
methscopolamine (Pamine)
d) Antidepressants-Selective Serotonin
Reuptake Inhibitors (SSRIs)
(1) Used to improve abdominal pain
(2) Examples: citalopram (Celexa)

CHAPTER 13

VI. Nausea and Vomiting


A. Pathophysiology
1. Three stages
a) Nausea is the subjective feeling of needing to
vomit.
b) Retching is a strong, belching-like, rhythmic
movement that may or may not be followed
by vomiting.
c) Vomiting (emesis) is the forcible expulsion
of stomach contents through the mouth.
2. The brain and the GI tract are involved in the
processes of nausea and vomiting, which
include chemoreceptor trigger zone (CTZ) in
the brain, the vestibular system, visceral
afferents from the GI tract, and the cerebral
cortex. The stimulation of the CTZ sends
impulse to the vomiting center. The CTZ
contains dopamine, histamine, acetylcholine,
serotonin receptors, and neurokinin-1.
B. Potential causes and risk factors
1. Chemotherapy
2. Diabetes (e.g., poorly controlled blood sugar)
3. Pregnancy
4. After surgery
5. Peptic ulcer
6. Stress
7. Gallstones
8. Gastroenteritis
9. GERD
10. Headache
11. Kidney failure
12. Liver disease
13. Motion sickness and vestibular disorders
14. Pancreatitis
15. Radiation
16. Toxins (alcohol)
17. Other
a) Female sex
b) Use of opioids during postoperative period
c) Negative smoking history
d) Obesity
C. Signs and symptoms
1. Nausea is a subjective sensation that is
difficult to define. It is an unpleasant feeling
in the abdomen often associated with the
sense of being ill and the urge to vomit. Other
related symptoms include increased salivation,
loss of color, sweating, tachycardia (increased
heart rate), and the urge to defecate.
D. Treatment
1. Home treatment
a) Drinking clear liquids only
b) Eating no solid food until the vomiting
episode has passed
c) Getting plenty of rest because more
movement and exertion may worsen the
symptoms
2. Medications
a) 5-HT3 antagonists
(1) Mechanism of action
(a) Blocks serotonin receptors
peripherally and centrally; when the
receptors are blocked, emesis is
suppressed

Gastrointestinal Disorders

155

(2) Adverse effects


(a) Headache and diarrhea
(3) Examples
(a) Dolasetron (Anzemet)
(i) Adults: 100 mg within 1 hour of
chemotherapy on days
chemotherapy is given
(ii) Children: 1.8 mg/kg (not to
exceed maximum dose of 100 mg)
within 1 hour of chemotherapy
on days chemotherapy is given
(b) Granisetron (Kytril): Adults: 2 mg PO
daily in single or divided doses
(q12h) within 1 hour of
chemotherapy on days
chemotherapy is given
(c) Ondansetron (Zofran)
(i) Adults, children 12 years and
older: 8 mg or 10 mL PO bid
(q12h) on days chemotherapy is
given and continued for 12 days
after chemotherapy ends
(ii) Children 411 years: 4 mg or 5
mL PO tid (q8h) on days
chemotherapy is given and
continued for 12 days after
chemotherapy ends
(d) Palonosetron (Aloxi): Adults, 0.25 mg
PO, 30 minutes before the start of
chemotherapy administration, day 1
of each cycle
b) Anticholinergics
(1) Mechanism of action
(a) Block acetylcholine at
parasympathetic sites in smooth
muscle, secretory glands, CNS
(2) Adverse effects
(a) Drowsiness
(b) Dry mouth
(3) Example
(a) Scopolamine: 0.30.65 mg IM, IV, or
SQ before surgery; 1 patch applied
q72h for motion sickness
c) Antihistamines
(1) Mechanism of action
(a) Block acetylcholine in vestibular
apparatus and H1 receptors in
vomiting center
(2) Drugs of choice for motion sickness
(3) Examples and typical adult doses
(a) Diphenhydramine (Benadryl): 1050
mg q46h given PO, IM, or IV
(b) Meclizine (Antivert): 12.5100 mg qd
in divided doses PO
(c) Promethazine (Phenergan): 12.525
mg q46h given PO, IV, or IM as
needed
d) Benzamides
(1) Metoclopramide (Reglan)
(a) Mechanism of action
(i) Activate 5-HT4 receptors and
block D2 receptors
(ii) Central and peripheral effects
(b) Common adult doses

156

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PHARMACOTHERAPY IN PRACTICE

(i) 12 mg/kg IV or PO for two doses


for acute chemotherapy-induced
N/V, given 2h apart
(ii) 0.51 mg/kg IV or PO q46h for
35 days for delayed
chemotherapy-induced N/V
(iii) 10 mg IV before the end of
surgery to prevent postoperative
N/V
e) Butyrophenones
(1) Mechanism of action
(a) Blocks D2 receptors at CTZ
(2) Example and typical adult dose
(a) Haloperidol (Haldol): 14 mg PO, IV,
or IM q6h as needed
f) Cannabinoids
(1) Mechanism of action
(a) The exact mechanism of action is not
well understood. It may be due to its
effects on cannabinoid receptors in
the central CNS
(2) Example and typical adult dose
(a) Dronabinol (Marinol): 520 mg PO
q36h, or 5 mg/m2 q24h upto 46
doses per day
g) Corticosteroids
(1) Mechanism of action
(a) May work by reducing inflammation
and/or enhancing efficacy of
dopamine and 5-HT3 antagonists for
chemotherapy-induced N/V
(2) Example and typical adult dose
(a) Dexamethasone
(i) 20 mg IV or PO, 30 minutes before
chemotherapy
(ii) 8 mg IV or PO bid for 2 days,
4 mg bid for 2 days for delayed
chemotherapy-induced N/V
(b) Methylprednisolone
(i) 40125 mg IV, 30 minutes before
chemotherapy
h) Phenothiazines
(1) Mechanism of action
(a) Inhibits D2 receptors at CTZ
(2) Examples and typical adult dose
(a) Prochlorperazine (Compazine):
1020 mg PO, IV, or IM q46h
(b) Perphenazine (Trilafon): 28 mg PO,
IV, or IM q6h
i) Neurokinin-1 receptor antagonist
(1) Aprepitant (Emend)
(a) Mechanism of action
(i) Inhibits the substance
P/neurokinin 1 (NK1) receptor
(b) Adverse effects
(i) Fatigue
(ii) Weakness
(iii) Dizziness
(c) Drug interactions
(i) Substrate and inhibitor of CYP450
3A4
(ii) Increases bioavailability of
corticosteroids

(a) Dexamethasone doses should be


decreased by 50% (oral)
(b) Methylprednisolone doses should
be decreased by 25% (IV) or by 50%
(oral)
(d) Aprepitant adult dose: 125 mg PO on
day 1, 80 mg PO on days 2 and 3
(i) Given with dexamethasone 12 mg
PO or IV on day 1, 8 mg PO or IV
on days 24
(ii) Given with ondansetron 1624
mg PO or 8 mg IV on day 1, plus
8 mg PO or IV on days 24

PATIENT PROFILE
Patient Initials: NB
Sex: Female
Age: 36 years
Height: 5 6
Weight: 55 kg
Race: White
Allergies: No known drug allergies (NKDA)
Chief Complaint: NB goes to the pharmacy to ask questions
regarding selection of products to treat heartburn. She
states troublesome symptoms of heartburn roughly 2 or 3
days a week) within several hours of ingesting a meal. The
symptoms began 2 weeks ago. She sometimes experiences
the symptoms at night after retiring. She cannot pinpoint
any specific dietary items that cause the heartburn to
appear. She needs assistance in selecting an over-thecounter (OTC) product. She has been ingesting Tums for
symptoms, and these help a bit, but the effect does not
last long and her heartburn returns.
Social History:
Tobacco use: None
Alcohol use: Minimal, socially only
Exercise: Walking several days per week, some weight
training
Medications:
Levothyroxine 75 mcg PO once daily (hypothyroidism
diagnosed 2 years ago, stable)
Laboratory: Not available
PATIENT PROFILE QUESTIONS
1. Certain patients with symptoms consistent with
heartburn or gastroesophageal reflux (GERD) are not
initial candidates for self-treatment. Which of the
following are considered reasons for physician
referral?
I. Difficulty swallowing (dysphagia)
II. Persistent symptoms (e.g., >3 months)
III. Symptoms occur >2 times per week
IV. Symptoms occur at night
a.
b.
c.
d.
e.

I only
II only
I and II
I, II, and III
All of the above

CHAPTER 13

Answer: c. If a patient has experienced symptoms


intermittently 12 or more times per week for just a
short period, self-treatment can be pursued for a
limited time. The patient should not have had chronic
or persistent symptoms for months. To be amenable to
self-treatment, a patient should not have any alarm
symptoms (e.g., pain or difficulty on swallowing,
choking, nausea with vomiting, bleeding, weight loss,
chest pain), or symptoms that might indicate other
problems (e.g., chest pain, jaw pain, dental erosion,
hoarseness of the voice, coughing, or wheezing). The
presence of any unusual or alarm symptoms should
prompt physician referral.
2. Which of the following would represent the BEST
choice for an initial nonprescription (OTC) regimen for
NB?
I. AcipHex 20 mg PO once daily
II. Prilosec OTC 20 mg PO once daily
III. Kapidex 30 mg PO once daily
IV. Pepcid AC 20 mg before meals known to cause
heartburn
a. I only
b. II only
c. III only
d. II or IV
e. III or IV
Answer: b. NB can choose an OTC regimen. Either II or
IV are potential regimens; the other two (AcipHex,
Kapidex) are prescription-only. Pepcid AC is not the
best choice for this patient because she cannot identify
triggering meals, and symptoms sometimes occur at
night hours. However, for many patients, a H2
antagonist like famotidine is a reasonable choice for
heartburn prevention if heartburn symptoms can be
tied to a trigger meal (e.g., pasta with tomato sauce) or
for treatment of heartburn if symptoms only occur
intermittently. A proton-pump inhibitor (PPI) is used
OTC when symptoms occur several times (>2 times)
per week and would help control symptoms in this
patient; this is probably the best choice at this time
given her history.
3. NB should also inform her physician of her use of a
proton-pump inhibitor (PPI) at her next doctor visit,
which is scheduled in 3 weeks. Why might she need to
tell her doctor about her heartburn and treatment?
I. Both her choice of antacid (Tums) and a PPI could
interfere with her levothyroxine prescription and
the maintenance of euthryoid status.
II. If her symptoms are not controlled in 2 weeks, she
will need to tell the physician and see if longer term
treatment or further evaluation is needed.
III. The PPI could interfere with other prescribed
medications, resulting in drug interactions.
a. I only
b. II only
c. II and III
d. I, II, and III
Answer: d. All of the above would be reasons for NB to
inform her doctor of her use of a PPI. The PPI may cause

Gastrointestinal Disorders

157

a change in levothyroxine absorption, and the patient


may need to have thyroid function tests monitored
more frequently and be aware of symptoms that could
indicate hypothyroidism if PPI treatment is continued. If
symptoms do not resolve in 2 weeks, the patient should
see a doctor for further evaluation, and the need for
other tests and or treatments. Because PPIs block
stomach acid and also may affect cytochrome P450
(CYP450) isoenzymes, they do have the ability to
interfere with other prescription medications. A PPI
should not be given with atazanavir, for example,
because the PPI substantially decreases the
bioavailability of atazanavir; atazanavir requires an
acidic environment for oral absorption.

REVIEW QUESTIONS
(Answers and Rationales on page 359.)
1. Lansoprazole is used to treat which of the following?
a. Hypertension
b. Congestive heart failure
c. Gastric reflux (GERD)
d. Peptic ulcer disease
e. c and d
2. Fiber-Con is:
a. used in the treatment of constipation.
b. used in the treatment of diarrhea.
c. to be avoided when taking tetracycline.
d. All of the above
e. None of the above
3. What class of drug is famotidine?
a. H1 receptor blocker
b. H2 receptor blocker
c. H3 receptor blocker
d. Gastrin inhibitor
e. COX-1 inhibitor
4. Which of the following is true of cimetidine?
a. It may cause confusion and dizziness.
b. It may cause hepatic dysfunction.
c. It is useful for the treatment of duodenal ulcers.
d. a and b
e. a, b, and c
5. Histamine can cause all of the following except:
a. Elevated blood pressure
b. Capillary dilitation
c. Gastric hypersecretion
d. Vascular permeability
e. Decreased airway mucus production
6. Which one of the following statements about Dulcolax
is true?
a. Normal oral dosing is 50100 mg.
b. It produces colonic mucosal irritation and fluid
secretion.
c. Oral onset of action is 24 hours.
d. It is 90% absorbed and secreted in the bile.
e. It should be ingested with a glass of milk for
maximum effect.

158

SECTION II

PHARMACOTHERAPY IN PRACTICE

7. Which of the following may cause breakdown of the


protective gastric mucosal barrier?
a. Aspirin
b. Ethanol
c. Caffeine
d. a and b
e. a, b, and c

14. Which one of the following drugs is most similar in


action to cimetidine?
a. Gaviscon
b. Imodium
c. Donnatal
d. Nexium
e. Axid

8. Which of the following statements is/are correct?


a. Atropine, when administered in full doses,
causes prolonged inhibition of stomach,
duodenum, jejunum, ileum, and colon
function.
b. Atropine reduces pancreatic sections.
c. Belladonna alkaloids significantly alter gastric
secretions.
d. All of the above
e. None of the above

15. Ranitidine may best be described as a(n):


a. antacid.
b. histamine receptor antagonist.
c. proton pump inhibitor.
d. cytoprotective agent.
e. anticholinergic agent.

9. True or False: Increases in blood urea nitrogen (BUN)


and serum creatinine (SCr) generally indicate liver
damage.
a. True
b. False
10. Which of the following medications is indicated for
treatment of chronic idiopathic constipation in
adults?
a. Loperamide
b. Octreotide
c. Lubiprostone
d. Opium tincture
e. None of the above
11. Select the correct statement(s) about sulfasalazine is
true?
I. It is a prodrug.
II. The active moiety is mesalamine.
III. It has its effect in the colon.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

12. Which of the following best describes the mechanism


of action of Anzemet?
a. 5-HT3 antagonist
b. Histamine antagonist
c. Beta-2 antagonist
d. Alpha-2 antagonist
e. None of the above
13. Which one of the following antiemetic medications
also decreases gastric emptying time?
a. Codeine
b. Metoclopramide
c. Dronabinol
d. Meclizine
e. Aprepitant

16. Select the over-the-counter (OTC) anti-nausea


medicine that is more effective than cyclizine?
a. Scopolamine
b. Promethazine
c. Diphenhydramine
d. All of the above
e. None of the above
17. Which of the following is an effect of antacids?
a. Inactivation of pepsin at alkaline pH
b. Decreased lower esophageal pressure
c. Increased gastric pH
d. Increased gastric motor activity
e. a and c
18. What is the effect of calcium or magnesium antacids
on tetracycline?
a. Increased toxicity
b. Enhanced activity
c. Decreased action
d. Suppression of adverse effects
e. No significant change
19. Which of the following conditions requires
consideration of the sodium, magnesium, or
phosphate content of a laxative before administration?
a. Ascites
b. Congestive heart failure
c. Renal insufficiency
d. a and c
e. a, b, and c
20. Which of the following acts via inhibition of the H/K
ATPase pump?
a. Omeprazole
b. Serotonin
c. Isoniazid
d. Misoprostol
e. Pirenzepine
21. Which of the following is a stimulant cathartic?
a. Mineral oil
b. Castor oil
c. Sodium citrate
d. Sodium bicarbonate
e. Methylcellulose

CHAPTER 13

Gastrointestinal Disorders

159

22. Which of the following is minimally absorbed


systemically?
a. Calcium carbonate
b. Aluminum hydroxide
c. Sodium bicarbonate
d. a and b
e. a, b, and c

30. Which of the following is NOT an appropriate


medication to treat esophagitis?
a. Amitriptilyne
b. Metoclopramide
c. Omeprazole
d. Dexlansoprazole
e. Cimetidine

23. Which of the following is a correct mechanism of


action of lactulose?
a. Induces osmotic diarrhea
b. Reduces fecal pH
c. Increases bacterial assimilation of ammonia
d. a and b
e. All of the above

31. Which of the following is NOT an adverse effect


associated with laxative use?
a. Spastic colitis
b. Dehydration
c. Intestinal obstruction
d. Hypokalemia
e. All of the above are potential side effects

24. Clearance of which of the following is NOT affected by


cimetidine?
a. Theophylline
b. Warfarin
c. Digoxin
d. Quinidine
e. Phenytoin

32. Which of the following statements about saline


cathartics is true?
a. They decrease surface tension of fecal matter.
b. They increase intestinal volume.
c. They are readily absorbed in the stomach.
d. They act more slowly than bulk-forming
laxatives.
e. They are safe to use in patients with renal failure.

25. Which of the following is an adverse effect of


prostaglandin E2?
a. Gynecomastia
b. Thrombocytopenia
c. Diarrhea
d. Headache
e. Seizure
26. Which of the following will be poorly absorbed in the
presence of aluminum hydroxide?
a. Penicillin G
b. Tetracycline
c. Cephalexin
d. Erythromycin
e. Chloramphenicol
27. Which of the following is no longer the most
appropriate agent to use in the treatment of peptic
ulcer disease?
a. Muscarinic antagonists
b. Prostaglandins
c. Antacids
d. Proton pump inhibitors
e. All of the above are appropriate

33. Which of the following is an indication for laxative


use?
a. Drug overdose
b. Prevent straining in patients with cardiovascular
disease
c. Diverticulosis
d. All of the above
e. None of the above
34. Which of the following is a possible mechanism
of laxatives?
a. Increases peristaltic activity
b. Increases stool bulk
c. Lubrication of stool
d. All of the above
e. None of the above
35. Select the statement regarding metoclopramide.
a. It causes extrapyramidal.
b. It blocks peripheral muscarinic synapses.
c. It decreases lower esophageal sphincter
pressure.
d. a and b
e. a, b, and c

28. Which of the following is the principal component


of emollient laxatives?
a. Magnesium hydroxide
b. Docusate
c. Bran
d. Methylcellulose
e. Phenolphthalein

36. Which of the following statements about sucralfate


is true?
a. It increases gastric motility.
b. It enhances Na/K-ATPase activity.
c. It antagonize gastrin.
d. It causes constipation.
e. It antagonizes acetylcholine.

29. Which of the following is a histamine-2 receptor blocker?


a. Sucralfate
b. Misoprostol
c. Ranitidine
d. Metoclopromide
e. Omeprazole

37. Which of the following acts as a saline cathartic?


a. Sodium phosphate
b. Sodium bicarbonate
c. Methylcellulose
d. a and b
e. a, b, and c

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PHARMACOTHERAPY IN PRACTICE

The following is a case study. Read the case study and


answer the questions after.
A 30-year-old woman presents to her physician with
complaints of chest pain for 3 months. She describes the
pain as substernal and epigastric, burning, and worse
after eating. She also complains of occasional
regurgitation of stomach contents. She reports some relief
with overthe-counter antacids.
38. What is the mechanism of gastroesophageal reflux?
a. Lower esophageal sphincter relaxation
b. Depressed esophageal mucus production
c. Increased acidity of gastric fluid
d. All of the above
e. None of the above
39. Which of the following is a potential complication of
gastroesophageal reflux?
a. Asthma
b. Laryngitis
c. Subglottic stenosis
d. Peptic stricture
e. All of the above
40. Which of the following is an appropriate initial
treatment for this patient?
a. Bethanechol
b. Cimetidine
c. Dextromethorphan
d. a or b
e. b or c
41. Which of the following is a potential side effect of
cimetidine?
a. Constipation
b. Headache
c. Urinary frequency
d. Hypotension
e. Hypothermia

42. This patient should be counseled to:


a. Elevate the head of her bed.
b. Wait at least 30 minutes after eating before lying
down.
c. Avoid aggravating foods.
d. Avoid smoking.
e. All of the above
43. What is the correct dosage of cimetidine for GERD?
a. 300 mg PO bid
b. 400 mg PO qid
c. 400 mg PO qd
d. 400 mg PO tid
e. 1000 mg PO qd
44. Cimetidine may interact with all of the following
EXCEPT:
a. warfarin
b. lidocaine
c. cyclosporine
d. dofetilide
e. All of the above
45. Peptic ulcers are caused by:
a. Infection
b. Long-term NSAID use
c. Spicy foods
d. a and b
e. b and c
46. The most common GERD symptoms are:
a. Laryngitis and hoarseness
b. Heartburn and regurgitation
c. Cough and wheezing
d. Stomach pains and diarrhea
e. Constipation and anal fissures

..................................................

14

Geriatrics

CHAPTER

....................................................................................................................................................................

I.

II.

Definitions
A. Geriatrics is the branch of medicine concerned
with the health care of the elderly. It aims to
promote health and to prevent and treat disease
and disabilities in older adults.
B. A geriatrician is a medical doctor who is specially
trained to prevent and manage the unique and,
oftentimes, multiple health concerns of older
adults. Geriatricians are able to treat older
patients, manage multiple disease symptoms, and
develop care plans that address the special health
care needs of older adults.
Conditions Commonly Seen in Geriatric Patients
A. Parkinson disease
1. Pathophysiology and epidemiology
a. Progressive, neurologic disorder due to
degeneration of presynaptic dopaminergic
neurons in the substantia nigra equals the
loss of postsynaptic dopamine activity in the
striatum (dopamine involved in inhibition of
cholinergic and glutamatergic loops and
increased activity in these systems)
b. Mean age of diagnosis: 5560 years;
incidence approximately 20/100,000;
mortality not greatly increased
c. Etiology of idiopathic Parkinson disease
unknown: possibly a combination of genetic
predisposition and environmental factors.
Hereditary accounts for less than 2% of all
diagnosed cases. Oxidative stress and free
radical damage may contribute to neuronal
degeneration.
d. Drug-induced: Caused by antidopaminergic
agents (metoclopramide, prochlorperazine,
neuroleptics, reserpine, methyldopa, etc.);
rarely amiodarone, selective serotonin
reuptake inhibitors (SSRIs), valproic acid,
diltiazem, verapamil
e. Treatment for drug-induced Parkinson
disease: discontinue drug, administer
anticholinergic agents (e.g.,
diphenhydramine or benztropine)
f. Other secondary causes: neurovascular
lesions, brain neoplasms, normal pressure
hydrocephalus, parathyroid abnormalities,
hypothyroidism, hepatocerebral degeneration,
CNS infection, toxins, head trauma
2. Signs and symptoms (Figure 14-1)
a. Onset: tremor, rigidity, akinesia, postural
instability

b. Minor: difficulty with fine coordinated


movements; postural disturbance (later in
disease state); flattened facial expression
(masked facies); voice may become
hypophonic, monotonal; shuffling gait;
micrographia; drooling, difficulty swallowing
liquids; pain in affected limb; depression or
dementia; constipation; orthostatic
hypotension; urinary frequency; sweating;
dermatitis; sexual dysfunction
c. Essential tremor characterized by an action
tremor (as opposed to resting tremor) is
commonly misdiagnosed as Parkinson disease
3. Treatment
a. The goal is to improve motor symptoms
(tremor, bradykinesia, rigidity), inhibit
cholinergic action, ease dopaminergic action
b. Guidelines differ regarding initial therapy:
dopamine first line versus last. Treatment
should not be initiated in most patients until
motor symptoms significantly impair quality
of life (QOL) and/or daily function.
1) Mild disease: amantadine (Symmetrel),
selegeline (selegline monotherapy
provides mild-to-modest relief of motor
symptoms and delays need for levodopa)
2) Dystonias and muscle cramps: baclofen
(Lioresal)
3) Tremor: anticholinergic agent like
benztropine (Cogentin)
4) Motor symptoms: anticholinergic drugs
such as benztropine in combination with
levodopa
c. All treatments are patient specific: doses
must be tailored and changed according to
patients disease state, progression, and side
effects.
d. Drug holidays: no longer widely
recommended due to risk of severe
immobility, aspiration pneumonia, venous
thromboembolism, depression
e. Adjunctive therapy to treat comorbidity:
depression, hallucinations, anxiety, constipation, orthostatic hypotension, pain, etc.
4. Nondrug therapy
a. Exercise, physical and occupational therapy,
speech therapy, nutrition (difficulty
swallowing may impair intake of foods;
constipation also a problem), psychological
support, and surgery
161

162

SECTION II

PHARMACOTHERAPY IN PRACTICE

Figure 14-1Signs and symptoms of Parkinsons disease.

(From
Monahan FD, Drake T, Neighbors M: Nursing care of adults. Philadelphia,
1994, Saunders)

5. Medications
a. Levodopa/carbodopa (Sinemet, Sinemet CR)
1) Mechanism of action: Levodopa is a
dopamine precursor that can cross the
blood-brain barrier and replace dopamine
in the brain (metabolized by dopadecarboxylase to dopamine). Carbidopa
inhibits peripheral dopa-decarboxylase
and allows more dopamine to enter brain,
which allows lower levodopa dose, morerapid dosage titration, and reduced
peripheral side effects (nausea/vomiting,
arrhythmias, orthostatic hypotension).
2) Usual dose: minimum 75100 mg/day
carbidopa required. Initial dose is one
carbidopa 25 mg/levodopa 100 mg tablet
PO three times per day. Levodopa
absorption is impaired by high-protein
meals.

3) Side effects (levodopa): nausea/vomiting,


insomnia or sedation, confusion,
hallucinations, dyskinesias, muscle
cramping (dystonias), wearing off
phenomenon (end-of-dose failure),
hypersexuality
4) Levodopa/carbidopa (Sinemet):
Approximately 5 years after initiation,
many patients experience motor
complications (wearing off phenomenon,
dyskinesia). Recent guidelines
recommend initiating a dopamine agonist
early in therapy, which delays need for
levodopa and complications of therapy.
As disease progresses, dopamine will be
needed.
b. Amantadine (Symmetrel): mildly effective
against tremor and rigidity
1) Mechanism of action: unclear, may be an
NMDA (N-methyl D-aspartate) antagonist;
blocks uptake and enhances the release
of dopamine
2) Has antiviral properties
3) Side effects: dry mouth, peripheral
edema, livedo reticularis, sedation,
confusion, hallucinations; may cause
insomnia if taken in late evening
(stimulating effect in some patients),
may be useful for young patients with
fatigue
4) Usual dose: 100 mg PO twice daily when
used as monotherapy; adjust for renal
impairment. For elderly: initially 100 mg
PO once daily; titrate the dosage carefully
upward if needed.
c. Selegiline (Eldepryl): mild to moderate
symptom relief as monotherapy in early
disease; also used for adjunctive therapy
late in disease to prevent wearingoff phenomenon. Some studies show
increased morbidity when used with
levodopa. Multiple other studies do not show
increased morbidity; however, may want to
avoid if patients have history of dementia,
frequent falls, or postural hypotension
1) Mechanism of action: selective,
irreversible MAO-B inhibitor. Selectivity is
lost if the dose is >20 mg/day;
metabolized to amphetamine/
methamphetamine
2) Side effects: insomnia, sedation,
confusion, agitation, hallucinations, vivid
dreams; may enhance levodopa-induced
dyskinesias
3) Contraindicated with meperidine
(Demerol)
4) Usual dose: 5 mg PO twice daily with
breakfast and lunch, may cause insomnia
if taken in late evening; consider lowering
levodopa dosage by 20% when starting
selegiline
5) Also available in orally disintegrating
tablet; maximum dose 2.5 mg/day

CHAPTER 14

d. Dopamine receptor agonists: bromocriptine


(Parlodel), pergolide (Permax), pramipexole
(Mirapex), ropinirole (Requip)
1) Dopamine agonists may be used as
monotherapy early in the disease;
adjunctive therapy in late disease to
manage motor complications
2) Usual dose: start doses low and titrate
slowly. It may take months to achieve
therapeutic dosage; taper up and taper
down. Reduce the dose in patients with
renal disease.
a) Bromocriptine: 1.25 mg PO twice
daily, increasing the total daily dose
by 2.5 mg every 1428 days until
the desired therapeutic response
occurs
b) Pergolide: this drug is discontinued in
the Unites States.
c) Pramipexole: initially, 0.125 mg PO
three times per day. Gradually
increase by 0.1250.25 mg/dose
(0.3750.75 mg/day) every 57 days
to a maximum dosage of 1.5 mg
PO three times per day
(4.5 mg/day).
d) Ropinirole: initially, 0.25 mg PO three
times per day for the first week.
Gradually titrate at weekly intervals to
a maximum of 24 mg/day.
3) Side effects: nausea/vomiting, constipation,
orthostatic hypotension, nightmares,
hallucinations, confusion, psychosis,
sedation, hypersexuality, yawning,
neuroleptic malignant syndrome (NMS)
e. Cateochol-O-methyltransferase (COMT)
inhibitors: tolcapone (Tasmar), entacapone
(Comtan)
1) These drugs are useful for wearing-off
phenomenon.
2) Mechanism of action: inhibits the action
of COMT
3) COMT inhibitors work with levodopa and
prolong its action. Because they affect
levodopa metabolism, they are only
effective in patients receiving levodopa
therapy.
4) Entacapone is a reversible peripheral
COMT inhibitor. It is the preferred COMT
inhibitor because it does not require liver
function test (LFT) monitoring. Tolcapone
is a peripheral and central COMT
inhibitor. It achieves greater COMT
inhibition than entacapone. However, its
use is restricted due to occurrence of
fatal hepatotoxicity; discontinue
tolcapone use after 3 weeks if patient fails
to show expected benefit from the drug.
Patients must give consent, and LFTs
should be performed every 2 weeks for
the first 12 months, then every 4 weeks
for the next 6 months, and then every
8 weeks for the duration of therapy.

B.

Geriatrics

163

5) Usual dose
a) Tolcapone: initially 100 mg PO three
times per day. The maximum
recommend dose is 600 mg/day PO
given in three divided doses.
b) Entacapone: 200 mg PO administered
with each levodopa/carbidopa dose to
a maximum of 8 times per day (1600
mg/day)
6) Side effects: exacerbation of levodopa
side effects, such as nausea, urine
discoloration (dark yellow to orangebrown), diarrhea (after several weeks). Be
alert to signs of liver problems, such as
worsening abdominal pain, yellowing of
the skin or whites of the eyes (especially
with tolcapone). Retroperitoneal fibrosis
and other lung problems are rare.
7) Drug interactions: Do not use with
nonselective MAO inhibitors. Iron
decreases absorption of both COMT
inhibitors; separate administration times.
d. Drug side effects
1) Nausea/vomiting: Patients should take
levodopa and dopamine agonists with
nonprotein snack. If antiemetics are
needed, do not use dopamine receptor
blockers (see section on drug-induced
Parkinson disease).
2) Hallucinations/psychosis: taper off
suspected agents until determination of
which agent caused the effect; if taper
causes significant worsening of Parkinson
disease, atypical antipsychotics should
be considered (avoid phenothiazine and
other traditional antipsychotics).
a) Quetiapine and clozaril are preferred
over olanzapine and risperidone
(latter two drugs may increase motor
symptoms)
3) Anticholinergics for tremor control:
trihexyphenidyl (Artane), benztropine
(Cogentin), diphenhydramine (Benadryl),
procyclidine (Kemadrin), biperiden
(Akineton)
a) Elderly are more sensitive to
anticholinergic side effects.
Alzheimer disease and dementia
1. Pathophysiology/epidemiology
a. Genetic factors: known to play a role in some
cases of Alzheimer disease (AD). Some families
with a history of early-onset AD have a mutation
on the amyloid beta precursor protein (APP)
gene. Another gene, the apolipoprotein (Apo)
E gene, also has been implicated in the disease.
Apo E is a protein found with beta amyloid
(a protein found in the brains of patients
with AD) in neuritic (inflamed nerve) plaques.
Together, these genetic mutations account for
less than 10% of all patients with AD.
b. Plaques and tangles: The causes of AD are
poorly understood, but its effect on brain tissue
has been demonstrated clearly. AD damages

164

SECTION II

c.

d.

e.

f.

PHARMACOTHERAPY IN PRACTICE

and kills brain cells. Neurons generate electrical


and chemical signals that are relayed from
neuron to neuron to help an individual think,
remember, and feel (physically and
emotionally). Brain chemicals called
neurotransmitters help these signals flow
seamlessly between neurons. Initially in people
with AD, neurons in certain locations of the
brain begin to die. When they die, lower levels
of neurotransmitters are produced, creating
signaling problems in the brain. One
neurotransmitter, acetylcholine, has been found
to be deficient in the brains of those with AD.
Medication treatment is based around
increasing the amount of acetylcholine in the
brain.
1) Plaques and tangles in brain tissue are
considered hallmarks of AD. Plaques are
made up of beta-amyloid, a normally
harmless protein. Although the ultimate
cause of neuron death in AD is not known,
mounting evidence suggests that a form of
beta-amyloid protein may be the cause. The
plaque is responsible for memory
deterioration in individuals with AD.
Inflammation: Researchers have observed
inflammation in the brains of some people with
AD. As beta-amyloid plaques develop in the
spaces between neurons, immune cells are
getting rid of dead cells and other waste
products in the brain. Although research has
found that the inflammation occurs before
plaques have fully formed, it is not known how
this development relates to the disease
process. There is also debate about whether
inflammation has a damaging effect on neurons
or whether it is beneficial in clearing away
plaques.
Age is the most important risk factor for AD.
The number of people with the disease doubles
every 5 years beyond age 65 years.
It is estimated that about five million Americans
have AD, and about 360,000 people are newly
diagnosed every year. AD affects about 10% of
people ages 65 years and older, and the number
doubles roughly every 10 years after age 65
years. Half of the population ages 85 years and
older may have AD.
Signs and symptoms
1) Mild symptoms: mental deterioration, such
as memory impairment and confusion,
difficulty learning and remembering new
information, difficulty with daily tasks, and
depression (sadness, decreased interest in
usual activities, loss of energy)
2) Moderate symptoms: forgetting old facts,
continually repeating stories, and/or asking
the same questions over and over,
deficiencies in intellect and reasoning, a lack
of concern for appearance, hygiene, and
sleep
3) Severe symptoms: groaning, screaming,
mumbling, or speaking gibberish, failing to

recognize the faces of family members or


caregivers, great difficulty with all essential
activities of daily life
4) Apraxia: inability to perform physical tasks
such as dressing, eating
5) Aphasia: loss of ability in comprehension of
spoken or written language
6) The primary symptoms of AD include
memory loss, disorientation, confusion, and
problems with reasoning and thinking. These
symptoms worsen as brain cells die and the
connections between cells are lost.
g. Medications
1) Cholinesterase inhibitors: donepezil
(Aricept), rivastigmine (Exelon), galantamine
(Razadyne), and tacrine (Cognex)
a) Mechanism of action: inhibits the
degradation of acetylcholine by inhibiting
the enzyme acetylcholinesterase
b) Usual doses
(1) Donepezil (Aricept): initial 5 mg/day
at bedtime; may increase to 10 mg/
day at bedtime after 46 weeks
(2) Rivastigmine (Exelon): initial 1.5 mg
twice daily; may increase by 3 mg/
day (1.5 mg/dose) every 2 weeks
based on tolerability (maximum
recommended dose 6 mg twice daily)
(3) Galantamine (Razadyne): initial 4 mg
twice a day for 4 weeks; if tolerated,
increase to 8 mg twice daily for 4
weeks; if tolerated, increase to 12 mg
twice daily; ranges 1624 mg/day in
two divided doses
c) Side effects: gastrointestinal effects
(diarrhea, nausea, vomiting, anorexia) are
most common and may require dose
reductions for some agents (e.g.,
galantamine). Increased salivation,
increased respiratory secretions,
bradycardia, headache, fatigue, and vertigo
are other side effects. Hepatotoxicity has
been attributed to the use of tacrine and
has limited the drugs clinical use.
d) Cautions: Individuals with liver disease,
peptic ulcer disease, chronic obstructive
pulmonary disease (COPD), and slow
heart rate should not take these drugs.
2) Memantine (Namenda)
a) Mechanism of action: NMDA antagonist,
blocks glutamate activity and prevents
excessive influx of calcium and, thereby,
neuronal death
b) Usual dose: Initial 5 mg/day; increase
dose by 5 mg/day to a target dose of 20
mg/day; wait at least 1 week between
dosage changes; doses >5 mg/day should
be given in two divided doses.
c) Side effects include headache,
constipation, confusion, and dizziness.
3) Other medications
a) Vitamin E
b) Selegiline (Eldepryl)

CHAPTER 14

C.

4) Adjunct therapies
a) Depression that occurs during the early
stages is commonly treated with
antidepressant medications, such as
selective serotonin reuptake inhibitors
(SSRI) including fluoxetine (Prozac) and
sertraline (Zoloft), and the tricyclic
antidepressants (TCA), including
amitriptyline (Elavil). Side effects include
drowsiness, fatigue, and sedation. TCA
may increase mental confusion.
b) Agitation may be treated with an
antipsychotic medication, such as
haloperidol (Haldol), risperidone
(Risperdal), olanzapine (Zyprexa), and
quetiapine (Seroquel). NOTE:
Antipsychotics are not FDA approved to
treat behavioral symptoms of AD and
may increase the risk for death in elderly
patients with dementia. Side effects
include sedation, confusion, and tardive
dyskinesia (an irreversible movement
disorder characterized by lip smacking,
facial grimacing, and unsteady walking).
Glaucoma
1. Pathophysiology and epidemiology
a. Glaucoma is the name given to a group of
conditions caused by increased intraocular
(inside the eye) pressure (IOP), resulting either
from a malformation or malfunction of the eyes
drainage system. Left untreated, an elevated
IOP may cause irreversible damage to the optic
nerve and retinal fibers, resulting in a
progressive, permanent loss of vision. However,
early detection and treatment can slow or even
halt the progression of the disease.
b. It is estimated that more than three million
Americans have glaucoma but only half of those
know they have it. Most individuals with
glaucoma are not aware of problems with their
vision. This is because the central vision (for
reading and recognizing people) is only affected
when glaucoma has advanced to a late stage.
Even when central vision is still good, glaucoma
may affect the vision needed for driving and
other daily functions, including seeing stair
steps or reading.
c. Approximately 120,000 are blind from
glaucoma, accounting for 9%12% of all cases of
blindness in the United States. About 2% of the
population 4050 years old and 8% older than
70 years of age have elevated IOP.
d. Glaucoma is the second leading cause of
blindness in the world, according to the World
Health Organization (WHO). Glaucoma is the
leading cause of blindness among African
Americans.
e. Estimates put the total number of suspected
cases of glaucoma at approximately 65 million
worldwide.
2. Most common forms of glaucoma
a. Open-angle glaucoma (chronic): Open angle
(also called chronic open angle or primary

Geriatrics

165

open angle) is the most common type of


glaucoma and usually causes no symptoms at
first. Even though the anterior structures of the
eye appear normal, aqueous fluid builds within
the anterior chamber, causing the IOP to become
elevated. Left untreated, this may result in
permanent damage of the optic nerve and retina.
b. Angle-closure glaucoma (acute): Acute angle
closure glaucoma, or closed-angle glaucoma,
occurs because of an abnormality of the
trabecular mesh work and the canal of Schlemm
in the eye that keeps aqueous humor fluid from
draining. In most of these cases, the space
between the iris and cornea is narrower than
normal, putting pressure on the canal of
Schlemm and leaving a smaller channel for the
aqueous humor to drain. If the flow of aqueous
becomes completely blocked, the IOP rises
sharply, causing a sudden angle closure
attack. Only about 10% of the population
with glaucoma has acute angle closure
glaucoma.
c. Secondary glaucoma: Secondary glaucoma can
develop as complications of other medical
conditions, such as inflammation, trauma,
previous surgery, diabetes, or a tumor. These
types of glaucoma are sometimes associated
with eye surgery or advanced cataracts, eye
injuries, certain eye tumors, uveitis (eye
inflammation), and certain medications
(including topical steroid creams, cocaine,
chlorpromazine or Thorazine, and phenelzine
or Nardil).
3. Signs and symptoms
a. Symptoms may vary depending on the type
1) Acute angle-closure glaucoma: Serious signs
and symptoms include eye soreness, blurred
vision, colored halos around lights, swollen
eyelids, severe eye pain, headache, and
nausea and vomiting.
b. Blind spots
c. Halos
d. Reddening around the eye
e. Blurred vision
f. Tunnel vision
g. Rise in eye pressure
h. Eye pain
i. Difficulty focusing
j. Loss of vision
4. Treatment
a. The treatment of glaucoma is aimed at reducing
IOP by improving aqueous humor outflow from
the eye, reducing the production of aqueous
humor, or both. These treatment goals are
accomplished with eye drops, systemic
medications, laser treatment, surgery, or a
combination of treatments.
5. Medications
a. Prostaglandin analogs
1) Mechanism of action: increases outflow of
aqueous humor
2) Adverse effects: may change the pigment of
the iris (may be permanent); may change

166

SECTION II

PHARMACOTHERAPY IN PRACTICE

direction of eyelashes (may be permanent)


and increase growth of eyelashes
3) Examples
a) Latanoprost (Xalatan): 1 drop (1.5 mcg) in
the affected eye(s) once daily at bedtime
b) Bimatoprost (Lumigan): 1 drop in the
affected eye(s) once daily at bedtime
c) Travoprost (Travatan): 1 drop in the
affected eye(s) once daily at bedtime
d) Unoprostone (Rescula): 1 drop in the
affected eye(s) twice daily
b. Sympathomimetics
1) Mechanism of action: increase outflow of
aqueous humor
2) Examples
a) Apraclonidine (Iopidine): used with other
drugs before surgery
b) Brimonidine (Alphagan): 1 drop in the
affected eye(s) three times daily (q12h)
c) Dipivefrin (Propine): 1 drop in the
affected eye(s) q12h
d) Epinephrine (Epifrin, Glaucon): 1 drop in
affected eye(s) daily or twice daily
3) Drug interactions: Some sympathomimetic
eye drops (e.g., brimonidine) should not be
used with MAO inhibitor therapy.
c. Beta blockers (nonselective)
1) Mechanism of action: suppresses production
of aqueous humor
2) Caution: Beta blockers are absorbed
systemically and should be used cautiously
in patients with heart, lung, or endocrine
disorders. The use of lacrimal occlusion
technique upon administration reduces
potential for systemic absorption of the eye
drops.
3) Examples
a) Timolol (Timoptic): 1 drop in the affected
eye(s) twice daily
b) Timolol gel (Timoptic XE): 1 drop once
daily
c) Carteolol (Ocupress): 1 drop in the
affected eye(s) twice daily
d) Levobunolol (Betagen): 12 drop(s) in
the affected eye(s) twice daily
e) Metipranolol (OptiPranolol): 1 drop in
the affected eye(s) twice daily
f) Combination product: Timolol/
dorzolamide (Cosopt): check for sulfa
allergy
d. Beta blockers (beta-1 selective)
1) Mechanism of action: suppresses production
of aqueous humor
2) Less effect on blood pressure and heart rate
compared with nonselective beta blockers.
The use of lacrimal occlusion technique
upon administration reduces potential for
systemic absorption of the eye drops.
3) Examples
a) Betaxolol (Betoptic): 1 to 2 drop(s) in the
affected eye(s) twice daily
b) Levobetaxolol (Betaxon): 1 drop in the
affected eye(s) twice daily

D.

e. Carbonic anhydrase inhibitors


1) Mechanism of action: suppresses production
of aqueous humor
2) Do not use in patients with sulfa allergy
3) Systemic preparations: not to be used as
monotherapy
4) Examples
a) Acetazolamide (Diamox): has been
associated with tachyphylaxis
b) Dichlorphenamide (Daranide)
c) Methazolamide (Neptazane)
f. Miotics (cholinergic)
1) Mechanism of action: increases outflow of
aqueous humor
2) Examples
a) Pilocarpine (Isopto Carpine, Pilocar): 1 or
2 drop(s) in the affected eye(s) three or
four times daily
b) Pilocarpine insert (Ocusert Pilo-20):
releases 20 mcg/h for 1 week; replace
once weekly
c) Carbachol (Isopto carbachol): two drops
in the affected eye(s) a maximum of three
times daily
Osteoporosis
1. Pathophysiology and epidemiology
a. Osteoporosis is more common in older
individuals and non-Hispanic white women, but
it can occur at any age, in men as well as in
women, and in all ethnic groups.
b. In the United States, about eight million women
and two million men have osteoporosis. Those
older than 50 years are at greatest risk of
developing osteoporosis and suffering related
fractures. In this age group, one in two women
and one in six men will have an osteoporosisrelated fracture at some point in their lives.
2. Signs and symptoms
a. In the early stages of bone loss, there usually is
no pain or symptoms. After bones have been
weakened by osteoporosis, signs and symptoms
may include back pain, which can be severe
with a fractured or collapsed vertebra; loss of
height over time, with an accompanying
stooped posture; and fracture of the vertebrae,
wrists, hips, or other bones.
3. Treatment
a. Nutrition and lifestyle
1) Dietary factors: calcium intake of 1200 mg
daily is recommended for adults older than
50 years. Adequate vitamin D intake is also
important for calcium absorption and to
maintain muscle strength; adults older than
60 years of age should take 600800 IU per
day. Milk and milk products are calciumdense foods providing about 300 mg of
calcium per serving. These foods also
contain other nutrients important to bone
health such as vitamin D (if fortified),
phosphorus, and magnesium.
2) Weight-bearing exercises: Weight-bearing
aerobic activities, involving the bones
supporting body weight, have a positive

CHAPTER 14

effect in maintaining and increasing bone


mass and preventing osteoporosis. These
activities include weight-lifting, jogging,
hiking, stair-climbing, step aerobics,
dancing, racquet sports, and other activities
that require muscles to work against gravity.
b. Medications
1. Bisphosphonates
a) Mechanism of action: inhibits osteoclastmediated bone resorption.
b) Dose: Alendronate (Fosamax) or risedronate
(Actonel) can be taken daily or are available
in a once-weekly dosage form; ibandronate
(Boniva) can be taken once a month. An IV
form of ibandronate is infused every 3
months. Another IV bisphosphonate is
zoledronic acid (Reclast); it is infused once
yearly.
c) Side effects: nausea, abdominal pain, and the
risk of an inflamed esophagus or esophageal
ulcers, especially if the individual has had
acid reflux or ulcers in the past.
Osteonecrosis of the jaw is a rare but serious
side effect.
1) A baseline and pre-dose determination of
serum creatinine is necessary in
individuals receiving IV bisphosphonates
to determine kidney function.
2) When taking an oral bisphosphonate,
proper administration is necessary to
reduce the risk of esophageal side effects.
Proper directions include: On the day of
dosing, take dose first thing in the
morning. Do not eat or drink anything
before taking medicine. Swallow with a
full glass (6 to 8 fluid ounces) of plain
water only. Do not chew or crush. After
taking, do not eat breakfast, drink, or take
any other medicines or vitamins for at
least 30 minutes. Stand or sit up for at
least 30 minutes after taking; do not lie
down.
d) Examples
1) Alendronate (Fosamax)
(a) Currently approved for management
of osteoporosis in both men and
women; also approved for the
prevention and treatment of steroidinduced osteoporosis in men and
women.
2) Risedronate (Actonel): like alendronate,
approved for the prevention and
treatment of steroid-induced
osteoporosis in men and women
3) Ibandronate (Boniva)
4) Zoledronate (Reclast)
e) Adequate calcium and vitamin D intake are
needed to achieve results.
2. Calcitonin salmon (Miacalcin):
a) A naturally occurring hormone produced by
the thyroid gland that can be given as an
injection or is more commonly used in
ambulatory settings as a nasal spray.

E.

Geriatrics

167

b) Mechanism of action: inhibits the function of


the cells that breakdown bone, the
osteoclasts
c) Dose
1) Miacalcin: IM or SC, 100 units every other
day
2) Fortical, Miacalcin: Intranasal 200 units (1
spray) in one nostril daily
d) Side effects: rhinitis, flushing, injection site
reactions, back pain, dizziness, fatigue,
nausea.
3. Teriparatide (Forteo)
a) Synthetic parathyroid hormone (PTH)
analog
b) Increases the number and action of
osteoblasts
c) Daily SC injections
d) Given to men and women with osteoporosis
at risk for bone fracture
4. Hormone replacement therapy (HRT)
a) Estrogen therapy alone or in combination
with another hormoneprogestinhas
been reported to decrease the risk of
osteoporosis and osteoporotic fractures in
women.
1) May increase risk of breast cancer with
long-term use
2) Example: conjugated estrogen (Premarin)
5. Selective estrogen receptor modulators (SERM)
a) Mimic the positive effects of estrogen on
bones without some of the undesirable and
serious adverse effects
b) Raloxifene (Evista)
1) Decreases spine fractures in women and
is approved for use only in women at this
time
2) Dose: 60 mg/day
3) Side effect: hot flashes; individuals with a
history of blood clots should not use this
drug.
6. Tamoxifen (Nolvadex)
a) Used to treat breast cancer; has some
beneficial effects on the bones and does not
stimulate the endometrium
Benign prostatic hyperplasia (BPH)
1. Pathophysiology/epidemiology
a. Benign prostatic hyperplasia (BPH) is a normal,
gradual enlargement of the prostate caused by
hormonal fluctuations, such as decreases in
testosterone and increases in
dihydrotestosterone (DHT) and estrogen in
prostate tissue. BPH usually begins in middle
age. BPH does not lead to cancer. BPH does not
generally cause pain, but there is often a
general discomfort (a feeling of pressure) in the
groin area.
b. As the prostate enlarges, it presses against the
urethra and interferes with urination. At the
same time, the bladder wall becomes thicker
and irritated and begins to contract, even when
it contains small amounts of urine, which
causes more frequent urination. Additionally, as
the bladder weakens, it may not empty

168

SECTION II

2.

3.

4.

5.

PHARMACOTHERAPY IN PRACTICE

completely, leaving some urine. Blocking or


narrowing of the urethra by the prostate and
partial emptying of the bladder cause many of
the problems associated with BPH.
c. BPH affects about half of men older than
60 years, and 80% of men aged 80 years or
older; it is considered to be a condition related
to aging. Almost every man older than 45 years
experiences some prostate enlargement, but
symptoms are rarely felt before the age of 60
years. BPH affects all men differently and
therefore treatment varies.
Diagnosis
a. Digital rectal exam (DRE)
b. Prostate-specific antigen (PSA) test
c. Prostate biopsy
Signs and symptoms
a. Delay in start of urine stream
b. Poor urinary flow and a variable flow rate
c. Frequent urination
d. Difficulty postponing urination (urgency)
e. Dribbling of urine at the end of urination
f. Nocturia (waking at night to urinate)
Treatment
a. Treatment options for BPH include lifestyle
changes, watchful waiting, drug therapy,
nonsurgical procedures, and major surgery. The
goals of treatment are to improve urinary flow
and decrease the symptoms an individual may
be experiencing. Treatment should also delay
or prevent the progression of BPH.
Medications
a. 5-Alpha reductase inhibitors: dutasteride
(Avodart), finasteride (Proscar)
1) Mechanism of action: inhibits the production
of the hormone DHT
2) Usual dose
a) Dutasteride (Avodart): 0.5 mg once daily
alone or in combination with tamsulosin
b) Finasteride (Proscar): 5 mg/day as a
single dose
3) Side effects: weakness, postural
hypotension, allergic reactions (skin rash,
itching or hives, swelling of the face, lips, or
tongue), change in sex drive or performance,
changes in breast-like lumps, pain or fluids
leaking from the nipple, pain in the testicles
4) Contraindications: pregnancy category X;
not indicated for use in women or children;
pregnant women or women trying to
conceive should not handle the products.
b. Alpha-1 blockers: alfuzosin (UroXatral),
doxazosin (Cardura), tamsulosin (Flomax),
terazosin (Hytrin)
1) Mechanism of action: blocks adrenergic
receptors on smooth muscle of the prostate
and bladder neck to improve urine flow and
to reduce bladder outlet obstruction
2) Usual dose
a) Alfuzosin (UroXatral): 10 mg once daily
b) Doxazosin (Cardura): immediate release:
1 mg once daily in morning or evening
may titrate to response; goal of 48 mg/

F.

day; maximum dose 8 mg/day. Extended


release: 4 mg once daily with breakfast;
titrate based on response and tolerability
every 34 weeks to maximum
recommended dose of 8 mg/day
c) Tamsulosin (Flomax): 0.4 mg once daily
30 minutes after the same meal each
day; dose may be increased after 24
weeks to 0.8 mg once daily to achieve
desired result
d) Terazosin (Hytrin): initial 1 mg at
bedtime, increasing as needed; most
patients require 10 mg day; if no
response after 46 weeks of 10 mg/day,
may increase to 20 mg/day
3) Side effects: dizziness, fatigue, headache,
orthostatic hypotension, muscle weakness
4) Contraindication and interaction:
concurrent use with phosphodiesterase-5
(PDE-5) inhibitors (commonly used for
erectile dysfunction) including sildenafil
(>25 mg), tadalafil, or vardenafil. Substrate
of CYP 3A4, avoid St. Johns wort, strong
inhibitors (ketoconazole, itraconazole,
ritonavir); beta blockers may enhance the
orthostatic effect of alpha-1 blockers
Erectile Dysfunction (ED)
1. Pathophysiology and epidemiology
a. Erectile dysfunction (ED), sometimes called
impotence, is the repeated inability to obtain or
retain an erection firm enough for sexual
intercourse. Impotence may also be used to
describe other problems that interfere with
sexual intercourse and reproduction, such as
lack of sexual desire and problems with
ejaculation or orgasm.
b. Estimates suggest that between 15 and 30
million (20%40%) Americans have ED. In men
40 to 69 years of age in the United States, the
incidence of new cases of ED is approximately
26 per 1,000 annually. More than 150 million
men worldwide have ED.
c. Risk factors: smoking, being overweight, eating
unhealthy foods (such as a high-fat diet),
avoiding exercise, the presence of diabetes or
vascular disease (atherosclerosis,
hypertension), and taking certain medications
(antidepressants, stimulants, anticholinergics,
antihypertensive agents)
2. Signs and symptoms
a. Occasional inability to obtain a full erection
b. Inability to maintain an erection throughout
intercourse
c. Complete inability to achieve an erection
d. Lack of morning erections are also seen along
with a decrease in sex drive (libido)
3. Treatment
a. Treatments include psychological
counseling, medications, mechanical devices,
and surgery. The cause and severity of ED
are important factors in determining the best
treatment or combination of treatments for
the individual.

CHAPTER 14

b. Medications
1. Phosphodiesterase-5 (PDE-5) inhibitors:
sildenafil (Viagra), tadalafil (Cialis), and
vardenafil (Levitra): first-line medication
a) Mechanism of action: inhibition of PDE-5 by
sildenafil causes increased levels of cyclic
guanosine monophosphate (cGMP) in the
corpus cavernosum, resulting in smooth
muscle relaxation and inflow of blood to the
corpus cavernosum
b) Usual dose
1) Sildenafil: usual dose 50 mg once daily
1 hour (range 30 minutes to 4 hours)
before sexual activity; dosing range
25100 mg once daily
2) Tadalafil: 10 mg at least 30 minutes
before anticipated sexual activity (dosing
range 520 mg); to be taken as one single
dose and not taken more than once daily
3) Vardenafil: 10 mg 60 minutes before
sexual activity; dosing range 520 mg; to
be taken as one single dose and not taken
more than once daily
c) Side effects: headache, reddening of the face
and neck (flushing), indigestion, insomnia,
pyrexia, and nasal congestion
d) Contraindications/drug interactions: Do not
use with organic nitrates in any form (e.g.,
nitroglycerin, isosorbide dinitrate), alpha-1
blockers, azole antifungals, protease
inhibitors.
2. Prostaglandin E1 analogs: alprostadil (Muse,
Caverject, Edex)
a) Mechanism of action: causes vasodilation by
means of direct effect on vascular and
ductus arteriosus smooth muscle; relaxes
trabecular smooth muscle by dilation of
cavernosal arteries when injected along the
penile shaft, allowing blood flow to and
entrapment in the lacunar spaces of the penis
b) Usual dose
1) Intracavernous (Caverject, Edex): no
more than three times per week with at
least 24 hours between doses
2) Intraurethral (Muse Pellet): Initial
125250 mcg; maintenance doses
administered as needed to achieve an
erection; duration of action is about
3060 minutes; use only two systems per
24-hour period
c) Side effects: penile pain, urethral burning,
headache, dizziness, pain
d) Contraindication and interaction: no
significant interactions
3. Yohimbine (Erex, Yocon)
a) Mechanism of action: has selective alpha2 adrenergic blocking properties, may
increase libido (sexual desire)
b) Side effects: elevated heart rate and blood
pressure, mild dizziness, nervousness, and
irritability
c) Contraindications: individuals taking MAOI or
antihypertensives; do not use in hypertensive
patients; avoid in individuals with BPH

Geriatrics

169

PATIENT PROFILE
Patient Initials: SR
Sex: Female
Age: 76 years
Height: 50 200
Weight: 40 kg
Race: White
Allergies: No known drug allergies (NKDA)
Chief Complaint/History: SR was recently found to have
Alzheimer disease. Before the diagnosis, her family
noted that she was constantly misplacing familiar items,
such as her keys and eyeglasses, and seemed to be
having difficulty remembering regular appointments
and medications. She also often speaks of certain longdeceased relatives as being still alive and sometimes
calls her son by her brothers name. Around the house,
she often leaves the stove on after cooking and
regularly seems to get disoriented. She seems more
irritable and anxious, even around familiar friends. Her
family is concerned about her ability to remain living at
home independently and recently started looking at
group homes focusing on care of patients with early
stage Alzheimer disease. This has been difficult because
SR gets angry during any conversations regarding
leaving her home.
Medical History:
Osteoarthritis
Hypertension
History of iron-deficiency anemia, no longer treated
Frequent urinary tract infections (UTIs)
Laboratories at last medical appointment:
Sodium: 137 mEq/L
Potassium: 3.9 mEq/L
Chloride: 110 mEq/L
CO2: 25 mEq/L
BUN: 22 mg/dL
Serum creatinine: 0.9 mg/dL
Glucose: 105 mg/dL
Cholesterol: normal
Liver function tests: within normal limits
CBC and differential: within normal limits
Urine: clear, no bacteria or protein
Social History:
Tobacco use: None
Alcohol use: None in recent years
Medications:
Lodine XL 400 mg PO once daily
Univasc 3.75 mg PO once daily
Hydrochlorothiazide 12.5 mg PO once daily

PATIENT PROFILE QUESTIONS


1. What is the estimated creatinine clearance (CrCl) for
this patient?
a. 110 mL/min
b. 40 mL/min
c. 34 mL/min
d. 70 mL/min

170

SECTION II

PHARMACOTHERAPY IN PRACTICE

Answer: c. 34 mL/min. In geriatrics, it is often important


to calculate an estimated creatinine clearance because
the serum creatinine level may not reflect renal
function due to declining muscle mass and organ
function. The Cockcroft-Gault equation is used
clinically when other means are not available. An
estimate of CrCl is important in the dosing of many
medications because many medications require
adjustment for renal impairment. The CrCl calculation
for this female patient is:
CrCl 0:85 

140  Patient age in years  Body weightKg


72  Serum Creatininemg=dL

0:85 

140  76  40
72  0:9

0:85 

2560
64:8

Answer 33.5 mL/min


34 mL/min
2. The physician would like to prescribe donepezil
(Aricept) for this patient. Which of the following
represents the correct starting dose?
a. 5 mg PO once daily
b. 10 mg PO once daily
c. 5 mg PO twice daily
d. 2.5 mg PO once daily
Answer: a. The initial starting dose for Aricept is 5 mg
PO once daily. No initial dosage adjustment is
necessary for renal impairment. The dose may be
titrated up to 10 mg PO once daily after 1 month to 6
weeks of treatment, if needed.
3. Which of the following regarding donepezil are true?
I. Common side effects are cholinergic in nature and
include nausea, diarrhea, GI disturbances, and
dizziness.
II. Treatment effect should be noticeable in a few days.
III. In early stage disease, the drug may help improve
concentration and focus on tasks of daily living and
help with orientation
IV. Progression of the dementia will be halted.
a. I only
b. II only
c. II and III only
d. I and III only
e. I, II, III, and IV are all true
Answer: d. Common side effects of donepezil are
cholinergic in nature, and the patient will usually notice
that these lessen after several weeks of treatment. If the
symptoms do not resolve, dose reduction may be
necessary to help tolerance. Treatment effect is usually
only noted after 46 weeks of use, and it is important for
the family to have an understanding of what results are
likely to be noticed, and when. Donepezil may help slow
the progression of the disease, but progression will
continue; the medication is not a cure.
4. After several months of treatment, SR is having difficulty
swallowing her medications. The patients family would
like her to remain on a cholinesterase inhibitor because

they feel she has done well on the medications. However,


they would like something that is not swallowed, if
available. They are concerned about choking. Which
medication comes in a nonoral dose form?
a. Rivastigmine
b. Galantamine
c. Tacrine
d. Donepezil
Answer: a. Rivastigmine is available as a transdermal
patch (Exelon) that can be removed and replaced
every 24 hours. Donepezil is available in an orally
disintegrating tablet (Aricept ODT) that can be easy to
swallow but is not available in a nonoral dosage form.
Rivastigmine (Exelon) and galantamine (Razadyne) are
available in oral solutions.

REVIEW QUESTIONS
(Answers and Rationales on page 361.)
1. What is akathisia?
a. Prolonged unilateral muscular spasms
b. Feeling of inner restlessness
c. Rigidity of the upper extremities
d. Inability to enjoy normal daily activities
e. Insomnia due to frequent muscular contractions
2. Which of the following statements regarding
Alzheimer disease is/are true?
I. Diagnosis is based on the exclusion of other
causes of dementia plus a review of history of
memory loss and other cognitive impairments.
II. Agitation associated with Alzheimer disease can
be treated with low doses of antipsychotics.
III. Cholinesterase inhibitors may improve memory.
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

3. Which of the following medications exhibit agerelated hepatic clearance changes?


I. Warfarin
II. Theophylline
III. Alprazolam
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

4. Levodopa is associated with which of the following


adverse effects?
I. Gastrointestinal upset
II. Orthostatic hypotension
III. Involuntary movements
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

CHAPTER 14

5. Which of the following drugs improves parkinsonian


symptoms via anticholinergic activity?
a. Benztropine
b. Trihexyphenidyl
c. Tolcapone
d. a and b
e. a and c
6. What is NOT true regarding levodopa therapy?
a. Levodopa monotherapy requires low doses
b. A dopa decarboxylase inhibitor is often
administered with levodopa
c. Tachycardia and ventricular extrasystoles are
adverse effects
d. All are false statements
e. All are true statements
7. Which of the following drugs improves symptoms of
Parkinson disease by increasing levels of dopamine in
the brain?
a. Selegiline
b. Bromocriptine
c. Levodopa
d. a and b
e. a and c
8. Which of the following symptoms is NOT associated
with hypothyroidism?
a. Decreased appetite
b. Drooping eyelids
c. Nervousness
d. All of the above
e. None of the above
9. Which of the following statements regarding
cholinesterase inhibitors is true?
a. They can be used to treat glaucoma.
b. They are ineffective in the treatment of
myasthenia gravis.
c. They decrease the smooth muscle tone of the
bladder.
d. a and b
e. a and c
10. Which of the following should NOT be used in the
treatment of glaucoma?
a. Pilocarpine
b. Timolol
c. Epinephrine
d. Atropine
e. Physostigmine
11. Alfuzosin relieves symptoms of prostatic hypertrophy
via:
a. alpha-1 blockage.
b. alpha-2 blockage.
c. beta-1 blockage.
d beta-2 blockage.
e. a and b
12. Total daily doses of levodopa should not exceed
________ per day.
a. 0.8 mg

b.
c.
d.
e.

Geriatrics

171

8 mg
18 mg
80 mg
800 mg

13. What effect does the addition of carbidopa have on


levodopa dosage?
a. Levodopa dosage is decreased by 50%.
b. Levodopa dosage is increased by 50%.
c. Levodopa dosage is decreased by 25%.
d. Levodopa dosage is increased by 25%.
e. Levodopa dosage is increased by 75%.
14. Which of the following should be avoided in patients
on levodopa?
a. Monoamine oxidase inhibitors
b. Carbidopa
c. Diphenhydramine
d. Amantadine
e. Benztropine
15. Which of the following side effects may occur with
levodopa?
a. Gastric upset
b. Reduced efficacy with prolonged use
c. Involuntary movements
d. a and b
e. a, b, and c
16. What is NOT true regarding amantidine therapy?
a. Is an antibiotic with dopaminergic function
b. Drug of choice in patients with Parkinsons
disease and seizures
c. Safer side-effect profile when compared to other
Parkinsons drugs
d. All of the above
e. None of the above
17. What body changes in the elderly can affect
pharmacokinetics of drugs?
a. Serum albumin
b. Body water
c. Blood glucose
d. a and b
e. b and c
18. Which of the following drugs is/are dopamine
receptor agonists?
I. Tranylcypromine
II. Pergolide
III. Bromocriptine
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

19. Which of the following drug classes is most often


associated with acute cognitive decline?
a. Diuretics
b. Benzodiazepines

172

SECTION II

c.
d.
e.

PHARMACOTHERAPY IN PRACTICE

Antidepressants
Antiarrhythmics
Antilipemics

20. Which of the following neurochemical changes is


most likely the cause of Parkinsons disease?
a. Increased dopamine
b. Decreased dopamine
c. Increased acetylcholine
d. Decreased acetylcholine
e. Increased serotonin
21. The most common community-acquired infection that
results in hospitalization for the elderly patient is:
a. Influenza
b. Tuberculosis
c. Urosepsis
d. Pneumonia
e. Infected pressure ulcers
22. Which of the following statements about carbonic
anhydrase inhibitors is FALSE?
a. They can be used preoperatively in acute angle
closure glaucoma.
b. They inhibit hydrogen ion excretion in the renal
tubules.
c. They are excreted in the urine predominately as
inactive metabolites.
d. They may cause ataxia.
e. All of the above are true
23. Pilocarpine:
a. may be used to treat chronic simple glaucoma.
b. may cause ciliary spasms.
c. is safe in patients with acute inflammation of the
anterior chamber.
d. a and b
e. a, b, and c
24. Phenylephrine:
a. is an alpha-adrenergic antagonist.
b. can be used to treat narrow-angle
glaucoma.
c. activates the pupillary dilator muscle to cause
contraction.
d. has a slow onset of action.
e. All of the above
25. Physostigmine:
a. may cause urinary retention.
b. inhibits acetylcholine degradation.
c. has a duration of action of 520 minutes.
d. is safe to use in patients with cardiovascular
disease.
e. All of the above
26. In which of the following patients is physostigmine
safe to use?
a. Patient with type 2 diabetes
b. Patient with GI obstruction
c. Patient with asthma
d. Patient with urinary obstruction
e. None of the above

27. Urinary incontinence:


I. Increases with age
II. Can lead to physical and social problems
III. Is more common in men than women
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

28. Alzheimers disease is defined as a:


a. Psychological condition
b. Disease of the arteries
c. Physical, degenerative disease of the brain
d. Temporary, reversible disease
29. Which of the following diseases or conditions may
cause dementia?
a. Head trauma
b. Vitamin b12 deficiency
c. Hypothyroidism
d. All of the above
e. None of the above
30. Which of these conditions may cause dementia?
a. Excessive exercise
b. Fatigue
c. Chronic alcoholism
d. Overeating
31. Geriatric patients are more sensitive to what drug
classes?
I. Antimicrobials
II. Opioids
III. Sedative-hypnotics
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

32. Which of the following is NOT a direct-acting alpha


agonist?
a. Metaproterenol
b. Amphetamine
c. Phenylephrine
d. a and b
e. a and c
33. Which following agents are selective for beta-1
adrenoceptors?
a. Brimonidine
b. Apraclonidine
c. Adrenaline
d. Betaxolol
e. Timolol
34. Parkinsons disease:
I. Impairs motor skills and speech
II. Is characterized by muscle rigidity and tremor
III. Is chronic and progressive

CHAPTER 14

a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

35. Which of the following statements is true?


a. Alpha agonists stimulate pre- and postsynaptic
receptors.
b. Cholinergic agonists antagonize acetylcholine at
muscarinic and nicotinic sites.
c. Atropine antagonizes acetylcholine at muscarinic
and nicotinic sites.
d. Ganglion blockers enter the CNS and have severe
CNS toxicities.
e. All of the above
36. Which of the following statements is correct?
a. Physostigmine and neostigmine are reversible
cholinesterase inhibitors.
b. Neostigmine is a tertiary amine and
physostigmine is a quaternary salt.
c. Neostigmine is the drug of choice for reversal of
central anticholinergic toxicity.
d. Neostigmine has severe adverse effects.
e. All are correct
37. Risk factors for glaucoma include the following:
a. Advanced age
b. Elevated intraocular pressure
c. African American heritage
d. Family history
e. All of the above
38. Where are cholinergic synapses NOT located?
a. Sympathetic ganglion cells
b. Motor end plates
c. Autonomic effector sites
d. Adrenal medulla
e. They are located at all of the above
39. Which of the following is most likely to cause the
following symptom constellation?
Iris radial muscle contraction
Hyperglycemia
Arteriolar constriction
a. Alpha agonist
b. Alpha antagonist
c. Beta agonist
d. Muscarinic agent
e. Antimuscarinic agent
40. Which of the following is true regarding
diphenhydramine?
I. Possesses local anesthetic activity
II. May be used to treat tremor of early Parkinsons
disease
III. Originally marketed as Bendectin
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

Geriatrics

41. Which best describes the mechanism of action of


donepezil?
a. Histamine antagonist
b. NMDA receptor antagonist
c. Acetylcholinesterase inhibitor
d. Beta-2 antagonist
e. None of the above
42. Primary open-angle glaucoma:
a. is more likely to result in blindness in blacks
than in whites.
b. usually has an onset in the second
decade of life.
c. can be treated with topical medications that
decrease aqueous outflow.
d. a and b
e. b and c
43. On ophthalmologic examination of an eye with
glaucoma, which of the following findings is
expected?
a. Optic nerve cupping
b. Retinal hemorrhage
c. Retinal exudates
d. Optic nerve edema
e. Vascular blebbing
44. Which of the following is the appropriate dosage
for immediate treatment of acute angle-closure
glaucoma?
a. 10% timolol
b. 10% apraclonidine
c. 20% apraclonidine
d. 2% pilocarpine
e. 20% pilocarpine
45. Risk factors for angle-closure glaucoma include:
a. male sex.
b. Asian race.
c. age older than 40 years.
d. a and b
e. b and c
46. Side effects of glaucoma treatments include:
I. Sweating for pilocarpine
II. Eyelid swelling for apraclonidine
III. Hypertension for timolol
a.
b.
c.
d.
e.

I only
III only
I and II only
II and III only
I, II, and III

47. Which best describes the mechanism of action


of entacapone?
a. Catechol-O-methyltransferase (COMT)
inhibitor
b. Alpha agonist
c. Acetylcholinesterase inhibitor
d. NMDA receptor antagonist
e. None of the above

173

174

SECTION II

PHARMACOTHERAPY IN PRACTICE

48. Which of the following is/are a direct-acting


cholinergic agonist?
a. Pilocarpine and propantheline
b. Pilocarpine and bethanechol
c. Propantheline and physostigmine
d. Physostigmine and muscarine
e. Physostigmine
49. Which of the following is NOT correct regarding
anticholinesterases?
a. They cause bronchoconstriction
b. They augment bronchiolar and lacrimal secretory
activity

c.
d.
e.

They cause urinary retention


The increase peristaltic activity
They cause miosis when applied topically

50. Which of the following is the most common joint


disorder in the elderly?
a. Neuropathic osteoarthropathy
b. Rheumatoid arthritis
c. Osteoarthritis
d. Osteoporosis
e. Gout

..................................................

Human Immunodeficiency Virus/


Acquired Immunodeficiency
Syndrome (HIV/AIDS)

15
CHAPTER

....................................................................................................................................................................

I.

Introduction and Definitions


A. The human immunodeficiency viruses (HIV-1 or
HIV-2) are the viruses that cause HIV infection and
the acquired immune deficiency syndrome (AIDS).
HIV primarily attacks the immune system, making
the patient extremely vulnerable to opportunistic
infections (infections caused by pathogens that
generally do not affect those with healthy immune
systems). HIV primarily infects and destroys
immune T-cells that have the CD4 receptor protein
on their cell surfaces (also called CD4-positive or
CD4 T-cells). Healthy individuals have a CD4
cell count between 600 and 1200 cells per
microliter of blood. HIV patients have less than 600
CD4 cells per microliter of blood; the lower the
CD4 count, the weaker the immune system.
B. When a patient is determined to be HIV-positive,
CD4 cell counts and the measurement of the HIVRNA level (a determinant of viral load) are assessed
to determine when treatment should be initiated
and with what medications. These tests are also
monitored on a regular basis after treatment is
initiated to determine clinical response. A lack of
clinical response to treatment may indicate viral
resistance or patient noncompliance, and a regimen
change may be needed.
C. HIV infection progresses to AIDS if the CD4 cell
counts drop to less than 200 cells per microliter.
This may happen if the infected individual receives
inadequate treatment or develops a major
infection. Individuals with a CD4 cell count less
than 200 have the greatest risk of developing
opportunistic infections, such as Pneumocystis
pneumonia (PCP), Mycobacterium avium complex
(MAC) infections, or Kaposi sarcoma.
D. According to the United States Centers for Disease
Control and Prevention (CDC), approximately
56,300 patients were newly infected with HIV in
2006, which is a 40% increase from the 40,000 annual
estimate used for past years. The increased number
may be due to more accurate lab testing and new
statistical methods, not a worsening of the
epidemic. The number of AIDS-related
deaths continues to decline, with an 8% decrease
from 2000 through 2004. Advanced treatments
can attribute to increased survival, thus resulting in
an increased number of people in the United States
who are living with HIV infection and AIDS.

II.

Signs and Symptoms


A. Many patients are asymptomatic when they first
become infected with HIV. One to 2 months after
infection, some HIV patients develop flu-like or
mononucleosis-like symptoms that last about 1 to
3 weeks. For the next several months or years,
patients usually do not experience any symptoms of
the disease. Once this asymptomatic period ends,
symptoms may include enlarged lymph nodes
(persistent lymphadenopathy), fatigue, weight loss,
frequent fevers and sweats, persistent or frequent
yeast infections of the mouth or vagina, persistent
skin rashes, flaky skin, pelvic inflammatory disease
(PID) in women, and short-term memory loss. As the
immune system continues to weaken, patients may
eventually progress to AIDS. During this stage,
patients have the greatest risk of developing lifethreatening opportunistic infections. HIV-related
cachexia, HIV-associated dementia, and certain
cancers may also occur in late-stage disease.
III. Treatment
A. Antiretroviral agents should be used in combination
with at least three agents, a strategy known as highly
active antiretroviral therapy (HAART). In the United
States, updated treatment guidelines, drug
information, and other resources formulated for
consumers and healthcare professionals can be found
at the following website: (www.aidsinfo.nih.gov)
B. Initial combination regimen (antiretroviral nave
patients): use either a nonnucleoside reverse
transcriptase inhibitor (NNRTI) or a protease
inhibitor (PI) or integrase strand transfer inhibitor
(INSTI) in combination with at least two nucleoside/
nucleotide reverse transcriptase inhibitors (NRTI):
1. one NNRTI two NRTI
2. single PI or ritonavir-boosted PI two NRTI
3. INSTI two NRTI
The selection of specific agents to use for a particular
individual is determined by efficacy and safety of the
agents in combination in controlled clinical trials,
and the regimens are individualized by considering
side effects, drug interactions, compliance factors
(pill burden), concurrent disease states, and other
factors. Combination dosage forms are available that
may help patients with compliance goals.
1. Individual antiretroviral agents used in
treatment of HIV-positive patients
(a) NRTI
175

176

SECTION II

Table 15-1

Brand
Name
Atripla

Combivir
Epzicom
Trizivir

Truvada

PHARMACOTHERAPY IN PRACTICE

Nucleoside/Nucleotide Reverse
Transcriptase Inhibitors (NRTI)
Combination Products
Active Ingredients
Efavirenz 600 mg,
Emtricitabine 200 mg,
Tenofovir 300 mg
Zidovudine 300 mg,
Lamivudine 150 mg
Abacavir 600 mg,
Lamivudine 300 mg
Zidovudine 300 mg,
Lamivudine 150 mg,
Abacavir 300 mg
Tenofovir 300 mg,
Emtricitabine 200 mg

Normal Adult
Dosage
1 PO qd

1 PO bid
1 PO qd
1 PO bid

1 PO qd

(i) Mechanism of action: cause chain


termination thereby inhibiting HIV viral
replication
(ii) Examples
a. Zidovudine (AZT; Retrovir)
b. Didanosine (ddI, Videx, Videx EC)
c. Lamivudine (3TC, Epivir)
d. Zalcitabine (ddC, Hivid)
e. Stavudine (d4T, Zerit)
f. Abacavir (ABC, Ziagen)
g. Emtricitabine (Emtriva)
(iii) Adverse effects (primary drug examples
noted in parenthesis where relevant):
a. All have boxed warning: lactic acidosis
with hepatic steatosis. Gastrointestinal disturbances (diarrhea,
nausea/vomiting), and headache are
common side effects of all.
b. Myelosuppression (including
neutropenia and anemia) (primary
example: zidovudine)
c. Pancreatitis (primary examples:
didanosine [boxed warning],
stavudine)
d. Peripheral neuropathy (primary
examples: zalcitabine and stavudine)
e. Fatal hypersensitivity reactions
(primary example: abacavir [boxed
warning], genetic screening required
before drug use with HLA-B*5701 test)
(iv) Avoid using these NRTI together due to
poor efficacy in combination:
a. Thymidine analogs: zidovudine
stavudine
b. Cytidine analogs: lamivudine
emtricitabine
(v) Use caution with these NRTI together
(regimens not recommended per expert
guidelines):
a. Didanosine stavudine due to
increased toxicities

b. Didanosine tenofovir due to drug


interaction; dose reduction of
didanosine required
(b) NNRTI
(i) Mechanism of action: bind to site on
viral reverse transcriptase, different
from NRTI; results in blockade of RNA
and DNA dependent DNA polymerase
activity
a. Does not compete with nucleoside
triphosphates
b. Does not require phosphorylation
(ii) Examples
a. Nevirapine (Viramune)
b. Delavirdine (Rescriptor)
c. Efavirenz (Sustiva)
d. Etravine (Intelence)
(iii) Adverse effects (primary examples in
parenthesis)
a. Rash; Stevens-Johnson syndrome
(nevirapine)
b. Elevated liver function tests (LFT);
severe hepatotoxicity (nevirapine)
c. Central nervous system (CNS)
symptoms (efavirenz)
d. Teratogenic (delavirdine and
efavirenz)
(iv) Drug interactions
a. Inhibitor of CYP3A4 (delavirdine)
b. Inducer of CYP3A4 (nevirapine)
c. Mixed induction/inhibition of
CYP3A4 (efavirenz)
d. St. Johns wort reduces activity of
all NNRTI and should be avoided.
(c) Protease inhibitors (PI)
(i) Mechanism of action: protease enzyme
cleaves precursor molecules to
produce mature, infectious virions
a. Inhibit protease and prevent the
spread of infection
b. Metabolized through the liver
through CYP3A4 pathway
(ii) Examples:
a. Atazanavir (Reyataz)
b. Darunavir (Prezista)
c. Fosamprenavir (Lexiva)
d. Indinavir (Crixivan)
e. Lopinavir/Ritonavir (Kaletra)
f. Nelfinavir (Viracept)
g. Saquinavir (Invirase)
h. Tipranavir (Aptivus)
i. Ritonavir (Norvir)
(iii) Adverse effects (common to many PI,
primary examples noted in parenthesis
where relevant)
a. Fat redistribution
b. Insulin resistance
c. Lipid abnormalities
d. GI intolerance
e. Headache
f. Hyperbilirubinemia (indinavir and
ritonavir)
g. Rash, including Stevens-Johnson
syndrome (amprenavir)

CHAPTER 15

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)

h. Hepatitis, intracranial hemorrhage


(tipranavir, boxed warning)
i. Nephrolithiasis (indinavir)
(iv) Drug interactions
a. St. Johns wort reduces activity of all
PI and should be avoided.
b. PI agents exhibit complicated drug
interaction profiles and drug
interactions should be reviewed for
each specific agent with proper drug
information resources. Ritonavir is
an especially potent inhibitor of CYP
isoenzymes.
(d) Nucleotide inhibitors
(i) Tenofovir (Viread)
a. Mechanism of action: competitively
inhibits HIV reverse transcriptase
and causes chain termination after
incorporation into DNA
b. Used in combination with other
antiretrovirals for HIV-1 suppression
(ii) Adefovir (Hepsera)
a. Mechanism of action: Competitively
inhibits HBV DNA polymerase and
results in chain termination after
incorporation into viral DNA
b. Used for hepatitis B, not for HIV
c. Adverse effects: nephrotoxicity
(e) Fusion inhibitors: Enfuvirtide (Fuzeon)
(i) Mechanism of action: binds to gp41
subunit and prevents conformational
changes for fusion
(ii) Dosage: 90 mg SC bid
(iii) Adverse effects: injection site
reactions, fever, flu like symptoms.
May cause allergic reactions.
(f) Entry inhibitor: Maraviroc (Selzentry)
(i) Mechanism of action: Blocks CCR5
receptor, one of the receptors HIV uses to
enter its target cell; prevents infection of
the cell
(ii) Used in treatment-experienced patients
(iii) Adverse effects: Cough, rash, dizziness.
May cause liver toxicity (boxed
warning), allergic reaction
(g) Integrase inhibitor: Raltegravir (Isentress)
(i) Mechanism of action: Interferes with
integrase, a viral enzyme responsible for
replication
(ii) Used in treatment-experienced patients
with documented resistant strains and
perguidelines can be used first line
treatment in naive patients
(iii) Adverse effects: Nausea, diarrhea,
headache. May cause myopathy and
rhabdomyolysis.
2. Treatment of specialized circumstances
resulting in HIV exposure
a. Vertical transmission, also known as motherto-child transmission
(1) Two drugs effective as monotherapy to
prevent perinatal transmission

177

(a) Zidovudine
(b) Nevirapine
b. Postexposure prophylaxis (HIV-PEP)
(1) Basic regimens
(a) Zidovudine lamivudine (available
as Combivir)
(b) Zidovudine emtricitabine
(c) Tenofovir DF lamivudine
(d) Tenofovir DF emtricitabine
(available as Truvada)
(i) Alternative regimens
a. Lamivudine stavudine
b. Emtricitabine stavudine
c. Lamivudine didanosine
(2) Expanded regimens consist of one of the
following
(a) Lopinavir/ritonavir (Kaletra)
(b) Atazanavir ritonavir
(c) Fosamprenavir ritonavir
(d) Indinavir ritonavir
(e) Saquinavir ritonavir
(f) Nelfinavir
(g) Efavirenz
(3) Antiretrovirals NOT generally
recommended for prophylaxis
(a) Nevirapine
(b) Delavirdine
(c) Abacavir
(d) Zalcitabine

References
1. Depiro J: Pharmacotherapy: A pathophysiological
approach, ed 7, McGraw-Hill Medical, 2008.
2. AIDS info, Clinical Guidelines Portal. US Department of
Health and Human Services. Available at: http://
www.aidsinfo.nih.gov/guidelines. (Accessed Feb 2,
2010)

PATIENT PROFILE
Patient Initials: KT
Sex: Male
Age: 33 years
Height: 50 1000
Weight: 64 kg
Race: Latin American
Allergies: Penicillin (rash)
Chief Complaint/History: None. Patient goes to clinic
pharmacy today for new highly active antiretroviral
therapy prescriptions; recently HIV regimen changed
due to HIV viral load studies and decreasing CD4
counts. Reyataz and Truvada are new prescriptions.
Medical History:
Diagnosed with HIV in 2001
Episode of Pneumocystis pneumonia (PCP) in 2006
Significant laboratories at last medical appointment:
CD4 cell count: 150 per mm3 (was >200 cells/mm3
6 months ago)

178

SECTION II

PHARMACOTHERAPY IN PRACTICE

a. I only
b. II only
c. III only
d. II and IV
e. I and III
Answer: e. To reach appropriate serum
concentrations for efficacy in this triple drug
antiretroviral regimen, Reyataz (atazanavir) is
boosted with Norvir (ritonavir), and the two drugs
are best taken at the same time to accomplish this.
Also, Reyataz is taken with food for best absorption.
The patient should be counseled with regard to
optimal drug administration and compliance.

Social History:
Tobacco use: 1 pack-per-day until 2002; none currently
Alcohol use: 1 glass of wine or a beer with dinner several
times per week
Medications:
Truvada 1 tablet PO q day (new)
Reyataz 150 mg, 2 capsules PO q day (new)
Norvir 100 mg, 1 capsule PO q day
Therapeutic multivitamin with minerals PO once
per day
PATIENT PROFILE QUESTIONS
1. When dispensing Norvir capsules to KT, which of the
following apply?
I. If stored at room temperature, the patient should
discard the capsules after 60 days.
II. The capsules are best stored refrigerated.
III. The capsules should be dispensed in the original
container.

4.

a. I only
b. II only
c. III only
d. I and III
e. II and III
Answer: b. If Norvir is stored at room temperature,
the capsules should be discarded after 30 days, not
60 days. There is no requirement to dispense the
capsules in the original container. Preferably, the
capsules are stored under refrigeration.
2.

3.

Based on current CD4 counts, the practitioner


decides that a PCP prophylaxis regimen should be
initiated. Which of the following is considered the
first-line regimen for prophylaxis of PCP?
a. Dapsone 100 mg PO every day
b. Bactrim DS 1 tablet PO every day
c. Atovaquone 750 mg PO twice daily
Answer: b. The combination of sulfamethoxazole
(SMZ) with trimethoprim (TMP) is considered first
line for PCP prophylaxis. Numerous trials have
indicated its effectiveness; patients taking SMZ-TMP
regimens have approximately a 5% chance of
developing PCP. SMZ-TMP treatment may also
prevent other infections, such as toxoplasmosis.
PCP prophylaxis is usually started when CD4 counts
are lower than 200, as is the case with KTs most
recent laboratories. The other regimens are
acceptable alternatives; however, atovaquone is
expensive, and is not always recommended by
organizations that govern guidelines for patients
with HIV.
Appropriate counseling regarding how KT should
take the Reyataz in the antiviral regimen include
which of the following?
I. Take at the same time as Norvir.
II. Take on an empty stomach, 2 hours before a
meal.
III. Take with food.
IV. Take at the same time as Truvada.

Which of the following are the most common side


effects for Truvada?
I. Diarrhea, nausea, headache, strange dreams,
sleeping problems
II. Lipodystrophy
III. Lactic acidosis
IV. Liver problems
a. I and II
b. II and III
c. III and IV
Answer: a. Lipodystrophy (change in distribution of
body fat) is a common side effect with longer use of
antiretroviral medications such as Truvada
(emtricitabine, tenofovir). The side effects listed in I
are the most common patients notice. Lactic acidosis,
liver problems (steatosis and hepatomegaly), kidney
problems, or pancreatitis are potential serious side
effects of this drug combination that are less
common.

REVIEW QUESTIONS
(Answers and Rationales on page 363.)
1. A 21-year-old, HIV-positive man presents to the HIV
clinic for examination. A PPD is placed, and when he
returns to clinic 3 days later, is found to be positive.
His LFTs are normal, and he is begun on anti-TB
therapy. In addition to clinical evaluation for adverse
events, what is the most appropriate monitoring
regimen?
a. Only clinical examination and interview is needed
b. Measure LFT monthly
c. Measure LFT every 8 weeks
d. Measure LFT at 2, 4, and 6 weeks
e. None of the above
2.

Which of the following are non-nucleoside reverse


transcriptase inhibitors?
I. Ganciclovir
II. Nevirapine
III. Efavirenz
a.
b.
c.
d.
e.

I only
III only
I and II
II and III
I, II, and III

CHAPTER 15

3.

4.

Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)

A 35-year-old HIV-positive woman goes to the


urgent care clinic with complaints of genital herpes.
She reports parasthesias for 4 days and developed
vesicular lesions on her labia this morning. The
patient explains that this is her third outbreak in
6 months. What is the most appropriate therapy?
a. Valacyclovir, 1 g PO bid for 5 days
b. Valacyclovir, 500 mg PO bid for 3 days
c. Famciclovir, 500 mg PO qd for 5 days
d. Acyclovir, 400 mg PO tid as continuous
suppressive therapy
e. Acyclovir, 400 mg PO tid for 3 days
A 30-year-old woman presents to the HIV clinic after
diagnosis at another hospital. Laboratory evaluation
reveals the following:
RPR: positive
FTA-ABS: positive
Lumbar puncture: 70 WBC, normal protein, negative
VDRL
The patient reports anaphylactoid reaction to
penicillin several years ago. What is the most
appropriate course of therapy?
a.
b.

Perform penicillin skin test followed by


desensitization
Benzathine penicillin G 2.4 mU IM q week for
3 weeks

c.
d.
e.

179

Benzanthine penicillin G 2.4 mU IM for one dose


a and b
a and c

5.

What statements are TRUE about protease inhibitors?


a. Ritonavir (Norvir), saquinavir (Invirase,
Fortovase) and indinavir (Crixivan) are examples
of protease inhibitors
b. Protease inhibitors inhibit cytochrome P450
oxidations
c. Select antihistamines and benzodiazepines are
contraindicated with protease inhibitors
d. All of the above
e. None of the above

6.

CO is a 35 year-old HIV-positive patient who is


receiving HAART regimen. About a month after
initiating therapy, he comes to the emergency
department complaining of severe flank pain,
frequent urination, and nausea. Which of the
following drugs is the most likely cause of his
symptoms?
a. Nevirapine
b. Indinavir
c. Didanosine
d. Efavirenz
e. Zidovudine

..................................................

16

Kidney Disorders

CHAPTER

...................................................................................................................................................................

I.

Background
A. The kidneys are responsible for removing toxins,
chemicals, and waste products from the blood;
regulating acid concentration; and maintaining
water and electrolyte balance in the body by
excreting urine.
Table 16-1

Stage
1
2
3
4
5

National Kidney Foundation Kidney


Disease Outcomes Quality Initiative
(NKF KDOQI) Staging System for
Chronic Kidney Disease

Description
Kidney damage with normal
or increased GFR
Kidney damage with a mild
decrease in GFR
Moderate decrease in GFR
Severe decrease in GFR
Kidney failure

Glomerular Filtration
Rate (GFR)
(mL/min/1.73 m2)
90
6089
3059
1529
<15 (or dialysis)

Reprinted from American Journal of Kidney Diseases, 39(2):35,


2002, with permission from Elsevier.

II.

180

Common Types and Causes of Kidney Disorders


A. Fanconi syndrome
1. Definition: The tubes in the kidneys do not work
properly.
a) Unable to reabsorb glucose, amino acids,
small proteins, water, calcium, potassium,
magnesium, bicarbonate, and phosphate,
making the blood overly acidic
b) May be caused by inherited disorders such
as cystinosis, galactosemia, glycogen
storage disease, hereditary fructose
intolerance, Lowe syndrome, Wilsons
disease, tyrosinemia, medullary cystic
disease, and vitamin D dependency;
exposure to heavy metals, certain drugs,
chemicals (e.g., toluene), or dietary
supplements (e.g., lysine); and may even
result from kidney transplantation
2. Signs and symptoms
a) Increased urination, excessive thirst,
dehydration, constipation, anorexia nervosa,
vomiting, high levels of sugar, phosphate,

calcium, uric acid, amino acids, and protein


in the urine, high levels of chloride and
low levels of phosphate and calcium in the
blood
3. Treatment
a) Replacement of fluids and nutrients lost in
urine
b) Addition of sodium bicarbonate, a diuretic
such as hydrochlorothiazide, and
supplementation with vitamin D and
phosphate
B. Glomerulonephritis
1. Definition: an acute or chronic kidney disease
that occurs when the kidneys are unable to
properly remove waste and excess fluids from
the body. This occurs when there is glomerular
damage from immune or inflammatory
reactions and lesions.
2. It can occur by itself or in conjunction with
other diseases such as lupus, Goodpasture
syndrome, diabetes, immunoglobulin A (IgA)
nephropathy, polyarteritis, Wegener
granulomatosis, or infection with
streptococcus, HIV, hepatitis B or C
3. Signs and symptoms: dark-colored urine, foamy
urine, high blood pressure, fluid retention that
causes swelling, fatigue, and less-frequent
urination
4. Treatment
a) The goal of treatment is to reduce the
decline of kidney function and control blood
pressure. Corticosteroids are often used to
reduce kidney inflammation. Diuretics,
angiotensin-converting enzyme (ACE)
inhibitors, angiotensin II receptor agonists
(ARB), calcium channel blockers, or beta
blockers may be used.
C. Focal segmental glomerulosclerosis (FSGS)
1. Definition: A type of glomerular disease that can
cause permanent kidney disease in children and
adults by attacking the glomeruli, the tiny
structures inside the kidneys where blood is
filtered. The most common sign of FSGS is the
nephrotic syndrome, which is characterized by
fluid in the body tissues that causes swelling,
excess protein in the urine, hypoalbuminemia,
and high cholesterol.
2. Signs and symptoms
a) Fatigue, nausea, headache, foamy urine,
weight gain, poor appetite, proteinuria

CHAPTER 16

b) Patients develop nephrotic syndrome, which


is characterized by fluid retention that causes
swelling and weight gain of 15 to 20 pounds or
more, foamy urine, abnormally low levels of
albumin in the blood, hypertension, and high
cholesterol. Fluid in the lung cavity,
abdomen, and in the sac that surrounds the
heart may build-up and fill the cavities.
c) Treatment
(1) Nonpharmacologic
(a) Reducing daily intake of salt to
2 grams
(b) Reduce fat intake
(c) Protein restriction
(2) Pharmacologic
(a) Immunosuppressants such as
prednisone, cyclophosphamide,
cyclosporine, or mycophenolate
mofetil may be used.
(b) Diuretics, ACE inhibitors, ARB,
calcium channel blockers, or beta
blockers may also be used for
treatment.
D. Kidney stones: Kidney stones (also called renal
calculi, urinary calculi, urolithiasis, or nephrolithiasis)
usually develop when the urine becomes too
concentrated. As a result, minerals and other
substances in the urine form hard crystals on the
inner surfaces of the kidneys. Over time, these
crystals may combine to form a small, hard mass, or
stone.
1. Calcium stones are the most common type of
kidney stones, accounting for 80% of cases.
Calcium stones develop when there are high
levels of calcium (hypercalcemia) and oxalate in
the blood.
2. Struvite stones are usually caused by chronic
urinary tract infections. The bacteria that cause
these infections release enzymes that increase
the amount of ammonia in the urine. This
excess ammonia may form large, sharp stones
that can potentially damage the kidneys.
3. Cystine stones develop in patients who have an
inherited disorder called cystinuria. This
disorder causes the kidneys to release too
many amino acids, which then form stones.
4. Signs and symptoms
a) Patients may experience intense pain that
comes and goes, lasting 5 to 15 minutes at a
time. Pain usually begins in the lower back and
moves to the abdomen, groin, or genital areas
as the stone moves from the kidney toward the
bladder. Other symptoms include blood in the
urine, cloudy or foul-smelling urine, nausea,
vomiting, and constant urge to urinate
5. Treatment
a) Calcium stones: Thiazide diuretics lower
urine calcium in idiopathic hypercalciuria
and are effective in preventing the formation
of stones.
b) Uric acid stones: The two goals of treatment
are to raise urine pH and to lower excessive
urine uric acid excretion to less than 1 g per

Kidney Disorders

181

day. Supplemental alkali, 13 mmol/kg of


body weight per day, should be given in
three or four evenly spaced, divided doses,
one of which should be given at bedtime.
c) Cystine stones: high fluid intake, even at
night. Daily urine volume should exceed 3 L.
Raising urine pH with alkali is helpful,
provided the urine pH exceeds 7.5.
d) Struvite stones: Complete removal of the
stone and subsequent sterilization of the
urinary tract is the treatment of choice for
patients who can tolerate the procedures.
Irrigation of the renal pelvis and calyces
with hemiacidrin, a solution that dissolves
struvite. For patients who are not candidates
for surgery, acetohydroxamic acid, and
inhibitor of urease, can be used.
E. Nephrotoxicity
1. Definition: A term used to describe toxic
damage in the kidneys; electrolytes in the
blood, including potassium and magnesium,
build up to toxic levels.
a) Certain medications, such as cyclosporine
(Neoral or Sandimmune), tenofovir (Viread),
intravenous vancomycin (Vancocin), and
systemic gentamicin (Garamycin) and other
aminoglycosides, may have toxic effects on
the kidneys.
2. Signs and symptoms
a) Increased urination, dark urine, blood in the
urine, and frequent urge to urinate
F. Diabetic nephropathy
1. Kidney disease that develops as a result of
diabetes mellitus (DM); most common cause of
kidney failure in the United States, accounts for
more than one third of all patients who are on
dialysis
2. Approximately 25% to 40% of patients with DM
type 1 ultimately develop diabetic nephropathy
(DN), which progresses through five
predictable stages.
a) Stage 1 (very early diabetes): above-normal
glomerular filtration rate (GFR)
b) Stage 2 (developing diabetes): GFR remains
elevated or has returned to normal, but
glomerular damage has progressed to
significant microalbuminuria (small but
above-normal level of the protein albumin in
the urine).
c) Stage 3 (overt, or dipstick-positive diabetes):
Glomerular damage has progressed to
clinical albuminuria.
d) Stage 4 (late-stage diabetes): Glomerular
damage continues, with increasing amounts of
protein albumin in the urine. The kidneys
filtering ability has begun to decline steadily,
and blood urea nitrogen (BUN) and serum
creatinine (SCr) has begun to increase. The GFR
decreases approximately 10% annually. Almost
all patients have hypertension at stage 4.
e) Stage 5 (end-stage renal disease [ESRD]): GFR
has fallen to approximately10 mL/min, and
renal replacement therapy (i.e., hemodialysis,

182

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PHARMACOTHERAPY IN PRACTICE

peritoneal dialysis, kidney transplantation) is


needed.
G. Nephrotic syndrome
1. Nephrotic syndrome is a disorder of the
glomeruli (clusters of microscopic blood
vessels in the kidneys that have small pores
through which blood is filtered) in which
excessive amounts of protein are excreted in
the urine (proteinuria). This typically leads to
accumulation of fluid in the body (edema), low
levels of the protein albumin
(hypoalbuminemia), and high levels of fats
(hyperlipidemia) in the blood.
2. Causes: DM, systemic lupus erythematosus,
amyloidosis certain viral infections,
glomerulonephritis, nonsteroidal antiinflammatory drugs (NSAID), allergies to insect
bites and to poison ivy or poison oak,
hereditary
3. Signs and symptoms: loss of appetite, a general
feeling of illness (malaise), puffy eyelids and
tissue swelling, abdominal pain, wasting of
muscles (atrophy), frothy urine, swollen
abdomen, shortness of breath, swelling of the
knees and, in men, the scrotum, shock. Blood
pressure is generally low in children and may
fall when the child stands up. Adults may
have low, normal, or high blood pressure,
urine production may decrease, and kidney
failure may develop if the leakage of fluid
from blood vessels into tissues depletes the
liquid component of blood and the blood
supply to the kidney is diminished. Other
signs and symptoms are in nutritional
deficiencies, growth may be stunted,
calcium loss from bones, brittle nails and
hair, hair loss
H. Drug-induced glomerular disease: Various drugs
damage the glomerular filtration barrier and
induce proteinuria and nephritic syndrome. Drugs
that may cause glomerular disease include NSAID,
recombinant interferon A, rifampin, penicillin,
ampicillin, amoxicillin, gold, penicillamine,
trimethadione, captopril, chlormethiazole,
ciprofloxacin, hydralazine, allopurinol,
sulfonamides, thiazides, warfarin, carbimazole,
heroin, and amphetamines
1. Acute renal failure (ARF): a syndrome
characterized by rapid decline in glomerular
filtration rate (hours to days), retention of
nitrogenous waste products, and perturbation
of extracellular fluid volume and electrolyte and
acid-base homeostasis. Discontinuation of the
offending agents such as NSAID and hydration
can be used to treat ARF.
I. End-stage renal disease (ESRD): End-stage kidney
disease is a complete or near complete failure of
the kidneys to function to excrete wastes,
concentrate urine, and regulate electrolytes.
End-stage kidney disease occurs when the
kidneys are no longer able to function at a level
that is necessary for day-to-day life. It usually
occurs as chronic renal failure worsens to the

point where kidney function is less than 10% of


normal. At this point, the kidney function is so low
that without dialysis or kidney transplantation,
complications are multiple and severe, and death
occurs from accumulation of fluids and waste
products in the body.
1. Treatment of renal disease
The following treatments are intended for
treatment or prevention of the worsening or
progression of renal disease
a) Diuretics
(1) Loop diuretics (furosemide, torsemide,
and bumetanide) inhibit the bodys
ability to reabsorb sodium at the
ascending loop of Henle, which leads to
a retention of water in the urine because
water normally follows sodium back into
the extracellular fluid (ECF).
(2) Thiazides such as hydrochlorothiazide
act on the distal tubule and inhibit the
sodium-chloride symporter leading to
retention of water in the urine as water
normally follows penetrating solutes.
Metolazone is not a true thiazide, but it
is a sulfonamide derivative such as
thiazides, and its site of action is similar.
Metolazone is an oral quinazoline
diuretic for the management of edema
and hypertension.
(3) Potassium-sparing diuretics such as
spironolactone, amiloride, and
triamterene do not promote the
secretion of potassium into the urine;
thus, potassium is spared and not lost as
much as in other diuretics.
(4) Osmotic diuretics (e.g. mannitol,
glucose) are filtered in the glomerulus,
but cannot be reabsorbed. Their
presence leads to an increase in the
osmolarity of the filtrate. To maintain
osmotic balance, water is retained in the
urine.
b) Albumin: Exogenous administration of
albumin increases the oncotic pressure of
the intravascular system, pulling fluids from
the interstitial space, thereby decreasing
edema and increasing the circulating blood
volume.
c) Antihypertensives (ACE inhibitors, ARB):
reduces the amount of protein in the urine
by reducing the amount of pressure and
resistance on blood as it circulates through
the body. Patients who cannot tolerate ACE
inhibitors may use an ARB (e.g., losartan,
valsartan). Both ACE inhibitors and ARB can
cause hyperkalemia (abnormally high level
of potassium in the blood) in patients with
chronic renal failure.
2. Dosing Adjustments: Dosages of renally
excreted drugs may need to be adjusted
according to kidney function. Dose adjustment
can be based on serum creatinine level,
subsequent creatinine clearance estimation,

CHAPTER 16

and dosage calculation. Cockcroft-Gault


equation or the Modification of Diet in Renal
Disease (MDRD) study equations may be used
for routine estimation of GFR.
a) Drugs that may require dosage adjustments
include ACE inhibitors, beta blockers,
diuretics, antimicrobial agents, some
hypoglycemic agents (metformin is not
recommended for use in patients with
kidney failure), some antimicrobial agents
(e.g., azole antifungals, acyclovir,
carbapenems, cephalosporins, penicillins,
quinolones), analgesics, statins, and others.
b) Dosing recommendations for individual
drugs can be found in Drug Prescribing in
Renal Failure: Dosing Guidelines for Adults
(Aronoff GR: Drug prescribing in renal failure:
dosing guidelines for adults, ed 4,
Philadelphia, 1999, American College of
Physicians)
3. Dialysis
a) Dialysis works on the principles of the
diffusion of solutes and convection of fluid
across a semipermeable membrane. Blood
flows by one side of a semipermeable
membrane, and a dialysate or fluid flows by
the opposite side. Smaller solutes and fluid
pass through the membrane. The blood flows
in one direction and the dialysate flows in the
opposite direction. The concentrations of
undesired solutes (e.g., potassium, calcium,
and urea) are high in the blood, but low or
absent in the dialysis solution, and constant
replacement of the dialysate ensures that the
concentration of undesired solutes is kept
low on this side of the membrane. The
dialysis solution has levels of minerals such
as potassium and calcium that are similar to
their natural concentration in healthy blood.
For another solute, bicarbonate, dialysis
solution level is set at a slightly higher level
than in normal blood, to encourage diffusion
of bicarbonate into the blood, to neutralize
the metabolic acidosis that is often present in
these patients.
b) There are two primary types of dialysis:
hemodialysis and peritoneal dialysis.
(1) In hemodialysis, the patients blood is
pumped through the blood
compartment of a dialyzer, exposing it
to a semipermeable membrane. The
cleansed blood is then returned via the
circuit back to the body.
(2) In peritoneal dialysis, a sterile solution
containing minerals and glucose is run
through a tube into the peritoneal
cavity, the abdominal body cavity
around the intestine, where the
peritoneal membrane acts as a
semipermeable membrane. The
dialysate is left there for a period of time
to absorb waste products, and then it is
drained out through the tube and

Kidney Disorders

183

discarded. This cycle or exchange is


normally repeated 4 to 5 times during
the day or sometimes more often
overnight with an automated system.
c) Continuous veno-venous hemofiltration
(CVVH): a short-term treatment, used in
patients with kidney failure. The kidney failure
may be new or already present. Hemodialysis
(kidney dialysis) is usually done for kidney
failure. However, if a patient has low blood
pressure, CVVH may be needed. As in dialysis,
in hemofiltration one achieves movement of
solutes across a semipermeable membrane.
However, solute movement with
hemofiltration is governed by convection
rather than by diffusion. With hemofiltration,
dialysate is not used. Instead, a positive
hydrostatic pressure drives water and solutes
across the filter membrane from the blood
compartment to the filtrate compartment,
from which it is drained. Solutes, both small
and large, get dragged through the membrane
at a similar rate by the flow of water that has
been engineered by the hydrostatic pressure.
Convection overcomes the reduced removal
rate of larger solutes (due to their slow speed
of diffusion) seen in hemodialysis.
J. IgA nephropathy is a common kidney disease that
progresses very slowly. It often leads to decreased
kidney function and ultimately to kidney failure.
The cause of this disease is not known, although
most people with the disease have abnormalities
in their immune system. Patients with IgA
nephropathy treated with immunosuppressive
drugs, such as steroids, may be less likely to
develop kidney failure.

PATIENT PROFILE
Patient Initials: AM
Sex: Male
Age: 43
Height: 50 1100
Weight: 180 lb
Race: White
Allergies: No known drug allergies (NKDA)
Chief Complaint/History: AM is admitted to the hospital
after progression of renal disease secondary to diabetes
(diabetic nephropathy). He will receive an arteriovenous
(AV) fistula and will begin dialysis sessions this week; a
central line is inserted for dialysis until the fistula is
deemed ready for use.
Medical History:
Diabetes type 2 for 10 years, has been insulin dependent
for 3 years
Hypertension
Family History: Significant for obesity, hypertension, and
cardiovascular disease. Father had myocardial infarction
(MI) last year at age 67.
Admission Laboratories:
Sodium: 136 mEq/L

184

SECTION II

PHARMACOTHERAPY IN PRACTICE

d. Caltrate
Answer: c. Tums EX and Caltrate are products
containing calcium carbonate. Renagel contains
sevelamer, a noncalcium-containing phosphate binder.
Phos-Lo contains calcium acetate. Sevelamer can be
added to a calcium-containing phosphate binder if
calcium dosing is maximized, but further phosphate
binding is needed to bring phosphate levels down. It
can also be used in place of calcium-containing
phosphate binders when a patients calciumphosphate product or calcium levels are too high.

Potassium: 5.0 mEq/L


Chloride: 102 mEq/L
CO2 content: 20 mEq/L
BUN: 60 mg/dL
Serum creatinine: 6 mg/dL
Glucose: 202 mg/dL
Calcium: 10.1 mg/dL
Phosphorous: 6.6 mg/dL
Albumin: 2.5 g/dL
Social History:
Tobacco use: None
Alcohol use: Occasional beer on weekends
Employment: Postal carrier, job requires several miles of
walking daily for deliveries
Medications before this admission:
Diovan 80 mg PO once daily
Furosemide 40 mg PO once daily
Humulin N insulin 20 units SQ in morning and 10 units in
evening
Insulin aspart, SQ sliding scale with meals; amount
adjusted based on carbohydrate intake
Calcium acetate 667 mg, 2 tablets PO three times daily
at meals
Nephro-Vite 1 tablet PO daily
PATIENT PROFILE QUESTIONS
1. All of the following are some of the potential
complications of chronic renal failure and end-stage
renal disease (ESRD) EXCEPT:
a. hyperphosphatemia.
b. hypokalemia.
c. anemia.
d. bone disease (renal osteodystrophy).
Answer: b. Renal insufficiency causes accumulation of
potassium, resulting in hyperkalemia (increased
serum potassium).
2.

3.

AM has edema on admission. What would be an


appropriate diuretic to add to AMs existing regimen
to reduce edema?
a. Bumex
b. Diuril
c. Zaroxolyn
d. Edecrin
Answer: c. Bumex and Edecrin are loop diuretics like
furosemide, and duplication of therapy is not
recommended. Diuril (chlorothiazide) is a thiazide
diuretic; thiazides are ineffective in patients with endstage renal disease and often lose effectiveness when
creatinine clearance is less than 30 mL/min.
Zaroxolyn (metolazone), unlike thiazide diuretics,
remains effective even when the glomerular
filtration rate drops to less than 30 mL/min.
Metolazone could be added to help with the acute
edema in this patient.
Which of the following brand names contains calcium
acetate?
a. Tums EX
b. Renagel
c. Phos-Lo

4.

Later in the week, AM develops symptoms consistent


with a Staphylococcus infection at the catheter site.
The decision is made to begin vancomycin until blood
culture results are known. Which of the following
represents an appropriate initial dose of vancomycin
at this time?
a. Vancomycin 1 g IV q12h
b. Vancomycin 1 g IV q24h
c. Vancomycin 1 g, given after dialysis, and dose
repeated after dialysis when needed according to
trough levels on dialysis days
d. Vancomycin 500-mg IV q12h
Answer: c. The first two answers would not be
appropriate for initial dosing in someone dependent on
renal dialysis. Initial doses are usually 12 to 15 mg/kg,
so the 500-mg dose is too small, and the interval of
dosing too frequent to provide therapeutic peak and
appropriate trough concentrations. Maintenance dosing
is adjusted according to trough levels following a dialysis
session until a preferred maintenance regimen is
identified and dialysis is stable; the frequency of dosing is
dependent on whether high-flux dialysis or low-flux
dialysis membranes and techniques are used. Typically,
low-flux dialysis methods remove little vancomycin
and dosing is generally every 72 hours to once per week.
High-flux dialysis methods remove more vancomycin
and typically dosing is more frequent, such as every
24-72 hours, following dialysis sessions.

REVIEW QUESTIONS
(Answers and Rationales on page 364.)
1. A 60-year-old patient is admitted for surgical
correction of a femoral fracture. Postoperative
laboratory evaluation revealed severe metabolic
acidosis (ph 7.0). What is the most appropriate
therapy for the metabolic acidosis?
a. Normal saline bolus
b. Sodium bicarbonate
c. Oxygen
d. Calcium gluconate
e. None of the above
2. Which of the following is a primary strategy used in
management of patients with acute glomerulonephritis?
a. High-protein diet
b. Maintenance of fluid balance
c. Correct high cholesterol
d. a and b
e. b and c

CHAPTER 16

3. Which of the following drugs acts on the renal


convoluted tubule to induce water resorption?
a. Vasopressin
b. Corticotropin
c. Testosterone
d. Estradiol
e. Insulin
4. A 58-year-old patient with renal failure secondary
to diabetes mellitus has anemia secondary to
renal disease. After an initial epoetinalfa dose
of 75 U/kg, three times per week, the patients
hematocrit increases from 22% to 30%. What is the
next appropriate step in management of this patient?
a. Cease erythropoietin therapy
b. Add ferrous sulfate
c. Increase the dose of erythropoietin
d. Continue the same dose of erythropoietin
e. Perform bone marrow biopsy
5. What is the normal range for blood sodium levels?
a. 420 mEq/L
b. 1656 mEq/L
c. 78122 mEq/L
d. 135146 mEq/L
e. 225275 mEq/L
6. JP is 57-year-old male that presents with fatigue and
the lab work shows advanced renal failure. Which
finding would help you determine if his renal failure is
chronic?
a. Low-serum bicarbonate
b. Low-serum calcium
c. Elevated-serum phosphorus
d. Waxy casts in urinalysis
e. Protein in urinalysis
7. Which of the following drugs is correctly paired with
its main site of action in the kidney?
a. Hydrochlorothiazide: descending limb of the
loop of Henle
b. Acetazolamide: proximal tubule
c. Triamterene: ascending limb of loop of Henle
d. Furosemide: collecting duct
e. Spironolactone: distal tubule

Kidney Disorders

185

8. KL is a 58-year-old female with a history of cirrhosis


and small-cell lung cancer. Her routine bloodwork
reveals a sodium level of 120 mEq/L. Which
laboratory test is most useful in determining which of
these diseases as the cause of hyponatremia?
a. Serum creatinine
b. Serum osmolarity
c. Urine osmolarity
d. Urine sodium
e. Serum vasopressin
9. WW is a 60-year-old male with chronic renal failure. The
patient develops abdominal cramping, nausea, and
vomiting from food poisoning. Laboratory examination
reveals: sodium 143, potassium 4.1, chloride 94, and
bicarbonate 24. What is your conclusion?
a. Metabolic acidosis
b. Respiratory alkalosis
c. Metabolic alkalosis
d. Normal acid-base balance
e. Metabolic alkalosis and metabolic acidosis
10. A patient with chronic renal failure was started on
erythropoietin for anemia. The hospital protocol
follows the manufacturers guidelines. The starting
dose was 75 U/kg three times a week and the patients
hematocrit was 25%. One month later, the patients
hematocrit is reported at 30%, and the patient is
asymptomatic. The hemoglobin is 10 g/dL. Which of
the following should the pharmacist do?
A. Increase the dose.
B. Continue the same dose.
C. Decrease the dose.
D. Stop the erythropoietin
11. Systemic alkalosis is most likely to be caused by:
a. mineral oil.
b. sodium bicarbonate.
c. methylcellulose.
d. castor oil.
e. sodium phosphate.

..................................................

17

Oncology

CHAPTER

...................................................................................................................................................................

I.

Definitions
A. Cancer: Typically defined as a group of diseases
characterized by uncontrolled and abnormal local
cellular growth, local tissue invasion, and distant
spread to other locations (metastases).
B. Second to cardiovascular disease for all-cause
mortality
C. Etiology
1. Carcinogenesis: process by which normal
mechanisms for control or growth and
proliferation of cells are altered
a. Initiation: exposure of normal cells to a
carcinogenic substance
b. Promotion: alteration of environment to
favor growth of mutated cell over normal
cells
c. Progression: genetic changes leading to cell
proliferation, invasion, and development of
metastasis
II. Risk factors
A. Environmental
1. Radiation
2. Virus
B. Occupational
1. Asbestos
2. Benzene, chromium, nickel
C. Lifestyle
1. Tobacco
2. Alcohol
3. Diet
III. Principles of tumor growth
A. Tumor growth is exponential.
B.